By Lisa Kropp, Coding & Credentialing Manager
BUNDLED SERVICES MISSING APPROPRIATE MODIFIERS AT TIME OF INITIAL CLAIM SUBMISSION
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 http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html