April 03, 2012 | | Comments 0
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NCCI edits more user-friendly despite some modifier confusion

CMS has recently made a number of improvements to the usefulness of the NCCI edits including a new format to the files effective this month.  Additionally, there have been some changes to the modifiers used to override NCCI edits, which warrants discussion of the 76, 77, 78, and 79 modifiers.

CMS has consolidated the NCCI edit files available for hospitals from 24 separate files into a single file.  Previously, CMS maintained 11 separate files for the distinct sections of the CPT (e.g. Surgery: Integumentary, Radiology Services, etc.), as well as a file for the HCPCS codes.  For each of these areas, they also maintained two files: one for the column 1/column 2 (bundling edits) edits and one for the mutually exclusive edits.  This was perhaps because Excel, the program used to publish the edits, limits number of lines in a worksheet.

The April 1 version of the hospital edits is available as a single file with 784,900 lines/edits.   This number of lines exceeds the Excel 2003 limit of approximately 65,000 lines.  Therefore, providers with Excel 2003 may not be able to view all the lines of the file.  The file is available on a distinct site set up just to explain the change to the format.

Consolidating the multiple files into a single file makes searching for edits much easier. Formerly, you had to open potentially four files to determine if an NCCI edit applied to a pair of codes.  Now you can simply search this one file.

This change follows another recent helpful change, effective January 1. For that version of the files, CMS made the hospital version of the files current, rather than being one quarter behind as they had been since the implementation of the edits for hospitals in CY 2000.  Read my October 31, 2011 blog post for more detail on how the delayed NCCI implementation caused problems for hospitals.


New NCCI manual

Another change that providers should be aware of initially slipped past unnoticed.  With all the other changes, CMS published a new version of the NCCI Policy Manual for Medicare Services, effective January 1, 2012.  The manual is downloadable as a zip file of several PDFs of individual chapters at this website.

In Chapter 1 of that manual, titled “General Correct Coding Policies”, they note that modifiers 76 (“Repeat Procedure or Service by the Same Physician or Other Qualified Health Care Professional”) and 77 (“Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional”) do not bypass the NCCI edits.  In looking at the 2010 version of the manual, this statement is not new, however, it is in contrast to FAQ 3739, last updated April of 2011, that included these two modifiers in a list of modifiers that did override NCCI edits.  Interestingly, the apparently incorrect FAQ was removed from the CMS website at some point in the last year rather than being updated with the new information.

Although modifiers 76 and 77 no longer appear to bypass NCCI edits, modifiers 78 (“Unplanned Return to the Operating/Procedure Room…for a Related Procedure in the Post-Operative Procedure”) and 79 (“Unrelated Procedure or Service by the Same Physician During the Post-Operative Period”) are still listed.   These two modifiers have a dual use for hospitals paid under the OPPS.  They bypass NCCI edits, but they also turn off the multiple procedure reduction logic which is not applicable if the two procedures were provided in separate surgical encounters on the same day.

For hospitals, modifier 59 (“Distinct Procedure Services”) seems to be used as a default modifier for multiple surgical procedures, particularly in separate departments or encounters.  Modifier 59 bypasses NCCI edits but it does not turn off the multiple procedures reduction and therefore it is not the best modifier if the two procedures occurred in separate surgical sessions.  If modifier 79 is used when the services occur in separate encounters, it will not only turn off the NCCI edit allowing both codes to be paid,  as does modifier 59, but it also allows the two codes to be paid at 100% per the applicable multiple procedure reduction policy.

For example, a patient presents to a provider based clinic for a small mole removal (11400) and later that day presents to the emergency department with a wound requiring repair of subcutaneous tissue (12031).   There is an NCCI edit bundling 12031 into 11400 and therefore if these two codes are billed on the same claim they will hit an edit and only the mole removal (11400) will be paid at $309.46.  If modifier 59 is applied to 12031 indicating the wound repair is separate from the mole removal, the mole removal (11400) will be paid at $309.46 and the wound repair (12031) will be paid at $113.90. The wound repair is paid at half the applicable rate because of the multiple procedure reduction.  However if modifier 79 is used, the procedures will both be paid at 100% (i.e., $309.46 for the mole removal (11400) and $227.80 for the wound repair (12031)) as is appropriate under the multiple procedure reduction policy because these two procedures were performed in separate surgical encounters.

There may be some concern with using modifier 79 because of the term “same physician” in the description.  In relationship to CPT codes, CMS states in section 20.2 Chapter 4 of the Medicare Claims Processing Manual:

 “the usage of the term ‘physician’ does not restrict the reporting of the code…to physicians only, but applies to all practitioners, hospitals, providers or suppliers eligible to bill the relevant CPT codes”.

Additionally, use of modifier 79 for unrelated procedures or services ‘by the same hospital’ in the post-operative period is consistent with correct payment under the multiple procedure reduction policy, which allows for 100% payment when two procedures occur in separate surgical encounters.

I encourage hospitals to take a look at how they are using the NCCI edits and modifiers. For many hospitals the above changes will be built into systems you already use.  However, pay special attention to the information about the modifiers, because it is up to the coders to select the correct modifier as appropriate when systems indicate a modifier is necessary.

Entry Information

Filed Under: CodingOPPS


Kimberly Hoy About the Author:

Kimberly Anderwood Hoy is director of Medicare and compliance for HCPro, Inc.

As a hospital compliance officer, Kimberly regularly provided research and guidance on coding, billing, and reimbursement issues for a wide range of hospital services. She has a particular expertise in charge description master operation, development, and maintenance. She has experience conducting billing compliance audits and internal investigations. Kimberly also has had primary responsibility for HIPAA privacy regulation compliance, including risk assessment, program development, implementation of policies and procedures, and ongoing operations.

As In-House Legal Counsel, Kimberly had oversight of expense contracting and regulatory compliance, including federal and state laws and regulations. Kimberly regularly provided legal advice on such complex topics as consents, EMTALA, Stark, anti-kickback and anti-inducement laws, physician recruiting, and tax exemption regulations.

Kimberly has served as a speaker at compliance-related conferences in the areas of compliance program effectiveness and physician education. Kimberly is an active member of the American and California Bar Associations, the American Health Lawyers Association and the Health Care Compliance Association.

Kimberly earned her Juris Doctor degree from the University of Montana School of Law, where she received the Corpus Juris Secundum Award for Excellence in Contracts. She also holds a Bachelor of Arts degree in Philosophy from Yale University.

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