1. National Correct Coding Initiative
HP Provider Relations
October 2010

2. Agenda National Correct Coding Initiative (NCCI) NCCI editing
Correct use of modifiers
Avenues of resolution

3. Objectives Understand what NCCI is
Understand who is affected and when the changes will take place
Understand the use of modifiers
Understand how to resolve NCCI questions

4. Change
National Correct Coding Initiative implementation

5. National Correct Coding Initiative
What is it?
In the 1990s, the Centers for Medicare & Medicaid Services (CMS) developed the NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payment
NCCI has been in place for many years and most providers are familiar with the editing methodologies used with Medicare
Based on input from a variety of sources:
American Medical Association (AMA) Current Procedural Terminology (CPT®) guidelines
Coding guidelines developed by national societies
Analysis of standard medical and surgical practices
Review of current coding practices
CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

6. National Correct Coding Initiative
The recent healthcare legislation passed into law (H.R. 3962), requires that Medicaid programs incorporate compatible methodologies of the NCCI into their claims processing system
Section 6507 mandates that NCCI methodologies must be effective for claims filed on or after October 1, 2010
Initial editing will encompass three basic coding concepts:
NCCI Column I and Column II
Mutually Exclusive (ME) Edits
Medically Unlikely Edits (MUE)

7. National Correct Coding Initiative
The NCCI Policy Manual is located at

8. National Correct Coding Initiative
How does it work?
NCCI editing is applied to claims reporting:
Same date of service
Same member
Same billing provider NPI
Also included in NCCI editing are:
Claims with Third Party Liability (TPL) amounts
Claims denied by the primary insurance

9. National Correct Coding Initiative
Who will be affected?
Included in NCCI:
Physician claims
Institutional outpatient claims
Type of bill 13X and 83X
Excluded from NCCI:
Medicare crossover
Dental
Home health
Hospice
Inpatient
Long-term care
Waiver
Pharmacy

10. National Correct Coding Initiative
When is implementation?
Professional claims – October 28, 2010
Includes column I/II, ME, MUE
Healthcare reform legislation mandates NCCI methodologies must be effective for claims filed on or after October 1, 2010
HP will mass adjust claims received on or after October 1, 2010, through the implementation date

11. National Correct Coding Initiative
Institutional outpatient
Outpatient claims targeted for April 1, 2011
Bill type 13X and 83X
Column I and Column II ME
MUE
HP will mass adjust claims received on or after October 1, 2010, through the implementation date

12. Define
Column I/Column II, MUE, and ME

13. New Edits for NCCI
New explanation of benefit (EOB) codes have been developed that specifically identify:
When a claim detail has encountered an NCCI edit
When a claim could not process through NCCI editing for an unexpected event
BT defines these edits including:
New EOB numbers
EOB Descriptions
Purpose of EOBs

14. New NCCI Edits Example New EOB EOB Description Purpose of EOB 4181
Service denied due to a National Correct Coding Initiative (NCCI) edit. Go to for information regarding NCCI coding policies.
This EOB will identify when a detail on a professional (CMS-1500) claim has denied for Column I/II and/or ME edit.
4183
Units of service on the claim exceed the Medically Unlikely Edit (MUE) allowed per date of service. Go to information regarding maximum number of units of service allowed for the service billed.
This EOB will identify when the units of service allowed on a claim detail exceed the MUE unit limit as defined by CMS.

15. New NCCI Edits Example New EOB EOB Description Purpose of EOB 4185
The claim did not process through NCCI editing. The claim will be reprocessed or adjusted at a later date. Please monitor future Remittance Advice statements for processing activity related to this claim.
This EOB will identify when a claim could not go through NCCI editing due to an unexpected event. The claim is allowed to continue through normal processing and will be subject to a mass adjustment at a later to date.
9092
The claim was subjected to NCCI editing methodologies.
This EOB will identify when a claim has gone through NCCI editing and did not encounter any Column I/II, ME, or MUE edits.

16. Column I and Column II Define
Column I/ Column II Procedures should be reported with the most comprehensive CPT code that describes the services performed
Physicians must not unbundle or report multiple Healthcare Common Procedure Coding System (HCPCS)/CPT codes when a single comprehensive HCPCS/CPT code describes the services that were furnished.

17. Column1/Column II Denial
Line #
From DOS
To DOS
Procedure Code
Description
NCCI Editing 01
11/01/2010
58260
Vaginal hysterectomy for uterus 250 grams or less
Detail is allowed 02
58720
Salpingo- oophorectomy, complete or partial, unilateral or bilateral
Detail is denied with edit 4181

18. Column1/Column II Denial
Line #
From DOS
To DOS
Procedure Code
Description
NCCI Editing 01
11/05/2010
70110
Radiologic exam, mandible: complete, minimum of four views
Detail is allowed 02
70100
Radiologic exam, mandible; partial, less than four views
Detail is denied with edit 4181

19. Mutually Exclusive Edits
Define
Procedure codes that cannot be reported together because they are mutually exclusive of each other
Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter
Two or more procedures performed during the same patient encounter on the same date of service and same billing provider that are not normally performed together

20. Mutually Exclusive (ME) Edits
Line #
From DOS
To DOS
Procedure Code
Description
NCCI Editing 01
11/15/2010
58280
Vaginal hysterectomy; with total or partial vaginectomy with repair of enterocele
Detail is allowed 02
58263
Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s), with repair of enterocele
Detail is denied with edit 4181

21. Mutually Exclusive (ME) Edits
Line #
From DOS
To DOS
Procedure Code
Description
NCCI Editing 01
11/21/2010
27440
Arthroplasty, knee, tibial plateau
Detail is allowed 02
27438
Arthroplasty, patella, with prosthesis
Detail is denied with edit 4181

22. Medically Unlikely Edits (MUE)
Define
HCPCS/CPTs have a defined unit of service for reporting purposes
Providers that bill units of service for a HCPCS/CPT code using a criteria that differs from the code’s defined unit of service will experience a denial
MUE editing is based on the units of service allowed on the claim, not the units of service billed

23. Medically Unlikely Edits (MUE)
Line #
From DOS
To DOS
Procedure Code
Description
Units of Service billed
NCCI Editing 01
12/11/2010
99232
Subsequent hospital care for the evaluation and management of a patient, patient is not responding to therapy or has a minor complication 6
Detail is denied with edit 4183 – Units of service on the claim exceed the Medically Unlikely Edit (MUE) allowed per date of service.
**If the dates of service were consecutive, the date span should represent the appropriate ‘From and To’ period. The MUE units allowed for this code is one per day.

24. Exceptions

25. Medically Unlikely Edits (MUE)
Exceptions
To align with current IHCP policy, the following are exceptions to the MUE unit limit:
A4253 – Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips:
The MUE unit limit is two and IHCP policy allows four units (or 200 test strips) per month
A4259 – Lancets, per box
The MUE unit limit is one and IHCP policy allows two units per month
These are examples only, not a complete list of unit limitations that may exist

26. NCCI Code Auditing Exceptions Antepartum Care
59425 – Antepartum care only; four to six visits
59426 – Antepartum care only; seven or more visits
Billed with modifiers
U1 – Trimester one – 0 through 14 weeks, 0 days
U2 – Trimester two – 14 weeks, one day through 28 weeks, 0 days
U3 – Trimester three – 28 weeks, one day, through delivery
And when billed on the same date of service as the lab codes listed in BT will not be subject to NCCI Column I/II editing
Chapter 8 of the IHCP Provider Manual “Obstetrical Care” section provides specific billing information and a complete list of lab services allowed for each trimester

27. Bill
Modifiers and date spans

28. Use of Modifiers What is correct?
Modifiers may be appended to HCPCS/CPT codes only when clinical circumstances justify the use of the modifier
A modifier should not be appended to a HCPCS/CPT code solely to bypass NCCI editing
The use of modifiers affects the accuracy of:
Claims billing
Reimbursement
NCCI editing
Clarification of procedures
Special circumstances

29. Use of modifiers
Correct use of modifiers is essential to accurate billing and reimbursement for services provided.
Chapter 8, Section 4 of the IHCP Provider Manual gives detailed descriptions of modifiers
The CMS provides carriers with guidance and instructions on the correct coding of claims and using modifiers through manuals, transmittals, and the CMS Web site
Providers can access the CMS Web site at
The National Correct Coding Initiative (NCCI) provides updates each quarter for correct modifier usage for each CPT code

30. Modifier 59 Distinct procedure or service on the same day
Should only be used when there is no other modifier to correctly clarify the procedure or service
A distinct procedure may represent the following:
Different session or patient encounter
Different procedure or surgery
Different site or organ system
Separate incision or excision
Separate lesion
Separate injury or area of injury in extensive injuries
If multiple units of the same procedure are performed during the same session, the provider should report all the units on a single detail line, unless otherwise specified in medical policy

31. Modifier 50 Bilateral procedure
Bilateral procedures performed during the same operative session on both sides of the body by the same physician
Units billed would be entered as 1 because one procedure was performed bilaterally
Modifier 50 is only required when the use of 50 is mandated by verbiage within the CPT coding manual

32. Modifier 51 Multiple procedures
Multiple procedures or services are performed on the same day or during the same operative session by the same physician
The additional or secondary procedure or service must be identified by adding modifier 51 to the procedure or service code

33. Modifiers LT and RT Procedures that can be performed on paired organs
Identifies procedures that can be performed on paired organs such as ears, eyes, nostrils, kidneys, lungs, and ovaries
Should be used whenever a procedure is performed on only one side to identify which one of the paired organs was operated on
CMS requires these modifiers whenever appropriate

34. Span Dates
CMS-1500
Providers must be sure to complete the “From” and “To” dates on all claims even if the service was for one single date of service
Services within the same calendar month and in a consecutive day pattern, must be billed with the appropriate units of service and “From” and “To” dates
Failure to report the correct date span and the number of units performed during the date span could result in a claim denial

35. Span Dates
Example
Detail is allowed and does not encounter NCCI edits.
From DOS
To DOS
Procedure Code
Description
Units of Service
10/03/2010
10/07/2010
E0202
Phototherapy 5

36. Web interChange Processing expectations
Claims are usually viewable within two hours via the Claim Inquiry function
On rare occasions, claims will not be available for viewing within the usual two-hour time frame
If the delay is longer than 24 hours, providers may contact HP Customer Assistance to determine the reason for the delay
, or
(317) in the Indianapolis local area

37. Inquire
Avenues of resolution

38. Claims Denials/Inquiry
Follow normal avenues of resolutions
IHCP Web site at
Customer Assistance
, or
(317) in the Indianapolis local area
Written Correspondence
Written Correspondence P.O. Box Indianapolis, IN
Provider relations field consultant

39. Claims Denials/Inquiry
New options
New options
– Column I and II, Mutually Exclusive (ME), and Medically Unlikely Edit files. These files contain specific code pairs for Column I /II and the Mutually Exclusive edits.
Administrative review

40. Administrative Review
Requirements
Administrative review must be requested within seven days of notification of claims payment or denial
Used when there are unusual circumstances in which a provider believes the claim was coded correctly and would like reconsideration of the NCCI editing
Complete an IHCP Programs Inquiry form or write a letter stating:
Reason for disagreement
Denial or amount of reimbursement
Clearly note “Administrative Review” on the form or letter
Attach all pertinent documentation
Add “Attention To: Health Care Administrative Review Specialist”
The IHCP Programs Inquiry form can be obtained from the Indiana Medicaid Web site in the forms section at

41. Administrative Review
Address
Send forms or letters to:
Attn: Healthcare Administrative Review Specialist Written Correspondence P. O. Box Indianapolis, IN

42. Contact

43. Concerns about Specific NCCI Edits?
For NCCI information only
Submit comments in writing to:
National Correct Coding Initiative Correct Coding Solutions, LLC P.O. Box 907 Carmel, IN
Send to the attention of Niles R. Rosen, M.D., Medical Director and Linda S. Dietz, RHIA, CCS, CCS-P, Coding Specialist
Send questions regarding NCCI table edits only; do not send claims questions or claim appeals

44. Questions