By Lisa Kropp, Coding & Credentialing Manager


National Government Services has published the following reminder to all providers:

Accurate coding and reporting of services are critical aspects of proper billing. Services denied based on the National Correct Coding Initiative (NCCI) code pair edits or Medically Unlikely Edits (MUEs) may not be billed to Medicare beneficiaries; a provider cannot utilize an Advance Beneficiary Notice of Noncoverage (ABN) to seek payment from a Medicare beneficiary. The NCCI tools found on the Centers for Medicare & Medicaid Services (CMS) Web site (including the “National Correct Coding Initiative Policy Manual for Medicare Services”) help providers avoid coding and billing errors and subsequent payment denials.

NCCI (also known as CCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. NCCI code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.

Modifiers may be appended to Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI edit if the clinical circumstances do not justify its use. If the Medicare Program imposes restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI edit if the Medicare restrictions are fulfilled.

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI edit include:

  • Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9,      LT, RT, LC, LD, RC, LM, RI
  • Global surgery modifiers: 24, 25, 57, 58, 78, 79
  • Other modifiers: 27, 59, 91

Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.

In addition to code pair edits, the NCCI includes a set of edits known as MUEs. MUEs have a maximum number of Units of Service (UOS) allowable under most circumstances for a single HCPCS/CPT code billed by a provider on a date of service for a single beneficiary.

Submit your claims correctly the first time, proper billing and accurate coding saves the provider and Medicare time and money!

For more information on Medicare’s NCCI edits, please visit the CMS Web site at




By Becky Amann, Compliance and Training Manager

COMPLIANCE WITH N.Y.S. DOH (Dept. of Health)

As a reminder, we notified you in April that Blue Cross issued a STAT Bulletin dated March 8, 2013, regarding Compliance to the NYSDOH Access and Availability requirements for their Medicaid Managed Care and Family Health Plus plans. NYSDOH indicated that many Blue Cross providers are not in compliance with the guidelines required by NYS Medicaid standards. If your practice does not comply, Blue Cross will be forced to apply monetary sanctions.

Please review the attached STAT regarding this compliance requirement. The bulletin can also be accessed via Blue Cross’s website at the link below. Please refer to Issue 3 – “Update your information for Access and Availability Standards”.—events/provider-bulletins/2013.html


CMS published MLN article SE1308 to provide clarification of Federal guidance regarding the Affordable Care Act as it relates to physician delegation of certain tasks in SNF’s and NF’s to nurse practitioners, physician assistants or clinical nurse specialists referred to as NPP’s.

Requirements for long-term care facilities indicate that a physician may not delegate a task when the regulations specify that the physician must perform it personally. Regulations also indicate the delegation of tasks may be prohibited under State law or by the facility’s own policies.

If you employ an NPP who provides services at a SNF or NF, please review this article on CMS’s website to determine which tasks may be delegated. The article can be accessed at:


All eligible professionals attesting to receive an incentive payment for either the Medicare or Medicaid EHR Incentive Program may be subject to an audit. CMS performs pre- and post-payment audits on Medicare and dually-eligible (Medicare and Medicaid) providers who participate in the EHR Incentive Program. States perform audits on Medicaid providers participating in the Medicaid EHR Incentive Program.

For more information regarding these audits, please access CMS’s website below and scroll down to “What Providers Need to Know about EHR Audits”.


The Medicare Quarterly Provider Compliance newsletter Volume 3, Issue 3 has been released. This educational tool is designed to provide education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Program. It includes information on corrective actions that health care professionals can use to address and avoid the top issues of the particular quarter.

This issue of the newsletter includes:  COMPREHENSIVE ERROR RATE TESTING (CERT) FINDINGS such as:

Split/Shared Evaluation & Management Services – Provider Types affected: Physicians and Non-Physician Practitioners

(A Split/Shared service is an encounter in which a physician and an NPP, such as a Nurse Practitioner (NP), Physician Assistant (PA), Clinical Nurse Specialist (CNS), or Certified Nurse-Midwife (CNM) each personally perform a portion of an E&M visit.)

  • The CERT Findings for Split/Shared services included insufficient documentation for CPT codes 99223 and 99211.
  • Recent CERT findings for insufficient documentation for 99223 included – The billing physician’s clinical documentation which supported the face-to-face evaluation and involvement in the E & M service billed was missing. Documentation from a follow-up call included a progress note written by the NPP and signed by the billing physician. The reviewer was unable to determine the physician’s involvement, other than signing the note.
  • Recent CERT findings for insufficient documentation for 99211  – An office visit note was not present to support that an evaluation and management service was performed. The documentation submitted for review included only laboratory results.
  • The two split/shared E & M CERT findings above, illustrate the importance of medical record documentation to support the proper E & M code.

To obtain guidance on how providers can avoid these problems, please review the newsletter at:

For Compliance questions, please contact Becky Amann at 716-348-3902 or