Public Policy

Code Correctly

A hospitalist who scrutinizes claims might notice a payment denial related to “unbundling” issues. Line-item rejections might state the service is “mutually exclusive,” “incidental to another procedure,” or “payment was received as part of another service/procedure.” Unbundling refers to the practice of reporting each component of a service or procedure instead of reporting the single, comprehensive code. Two types of practices lead to unbundling: unintentional reporting resulting from a basic misunderstanding of correct coding, and intentional reporting to improperly maximize payment of otherwise bundled Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes.1

The initial NCCI goal was to promote correct coding methodologies and to control improper coding, which led to inappropriate payment in Part B claims.

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) for implementation and application to physician claims (e.g., Medicare Part B) with dates of service on or after Jan. 1, 1996. The rationale for these edits is a culmination of:

  • Coding standards identified in the American Medical Association’s (AMA) CPT manual;
  • National and local coverage determinations developed by CMS and local Medicare contractors;
  • Coding standards set forth by national medical organizations and specialty societies;
  • Appropriate standards of medical and surgical care; and
  • Current coding practices identified through claim analysis, pre- and post-payment documentation reviews, and other forms of payor-initiated audit.

FAQ

Q: Can a physician override NCCI edits?

A: Yes. NCCI code pairs are assigned a status. This status is identified as a code pair superscript. The code pair superscript can be 0, 1, or 9: “0” means that a modifier is not allowed at all, and will not override an edit; “1” means that a modifier is allowed, when appropriate, for two services or procedures that were performed at separate sessions or separate sites during the same session; and “9” means that the edit is no longer applicable.

The most common example of a hospitalist reporting two “bundled” services together occurs when an evaluation and management (E/M) service (e.g., 99233) is reported with a critical-care service (99291) on the same day by the same physician or physicians of the same specialty in a provider group. Per Medicare guidelines, both critical care and an E/M service can be paid, but only if the inpatient E/M service was furnished early in the day when the patient did not require critical care, yet required it later that same day.5

Alternatively, once critical care is initiated, any subsequent evaluations (on the same day) are counted toward critical-care time (as in the above scenario). After meeting the guidelines for reporting these two services together, the hospitalist appends modifier 25 to the “bundled” E/M: 99291, 99233-25. Documentation must support this situation, as it likely will need to be sent to the insurer before payment is obtained.

The initial NCCI goal was to promote correct coding methodologies and to control improper coding, which led to inappropriate payment in Part B claims.2 It later expanded to include corresponding NCCI edits in the outpatient code editor (OCE) for both outpatient hospital providers and therapy providers. Therapy providers encompass skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy (OPTs) and speech-language pathology providers, and home health agencies (HHAs).

Fact-Check

The NCCI recognizes two edit types: Column One/Column Two Correct Coding edits and Mutually Exclusive edits. Each of these edit categories lists code pairs that should not be reported together on the same date by either a single physician or physicians of the same specialty within a provider group.

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