Identify Code Edits Before They Hold Up Claims

Identify Code Edits Before They Hold Up Claims

Section-specific examples have been added to the Medicare National Correct Coding Initiative (NCCI) Policy Manual. These examples reveal the rationales behind the edits contractors use to vet medical claims for incorrect code combinations.

Take the Initiative to Correct Coding

The Centers for Medicare & Medicaid Services (CMS) implemented the NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payment.

Procedure-to-Procedure (PTP) code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.

Medically Unlikely Edits (MUEs) look for a maximum number of units of service allowable under most circumstances for a single HCPCS Level II or CPT code billed by a provider on a date of service for a single beneficiary.

New Rationales Explain NCCI Edits

The NCCI Correspondence Language Manual for Medicare Services provides general language and section-specific examples for PTP edits and MUEs. Following are revisions that are effective April 1, 2018.

Musculoskeletal System CPT Codes 20000-29999

Under Correspondence Language Policy/Example Number 3.20000 – CPT Manual or CMS manual coding instruction, a new example is added:

For example, the parenthetical note following CPT code 20611 states: “(Do not report 20610, 20611 in conjunction with 27370, 76942).” Thus, CPT codes 27370 and 76942 should not be reported with arthrocentesis procedures described by CPT codes 20610 and 20611.

Respiratory System, Cardiovascular System, Hemic and Lymphatic Systems, Mediastinum and Diaphragm CPT Codes 30000-39999

Under Correspondence Language Policy/Example Number 10.30000 -Standards of medical/surgical practice, a new example is added:

For example, CPT code 30160 describes a total rhinectomy. CPT code 30110 describes simple excision of a nasal polyp(s). If nasal polyps are present when a total rhinectomy is performed, excision of the polyp(s) is an inherent component of the rhinectomy. Therefore, CPT code 30110 should not be reported separately with CPT code 30160.

Tip: Be sure to read Explore 2018 Changes for Otolaryngology (HBM January 2018) by Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow.

CPT Category III Codes (0001T-0999T) (Temporary CPT Codes for Emerging Technology, Services, and Procedures)

Under Correspondence Language Policy/Example Number 2.0000T – HCPCS/CPT procedure code definition, a new example is added:

For example, CPT code 0054T describes a computer-assisted musculoskeletal surgical navigational orthopedic procedure with image-guidance based on fluoroscopic images. CPT code 76000 describes fluoroscopy. Therefore, based upon the code descriptors the procedure described by CPT code 76000 is a component of the procedure described by CPT code 0054T, and CPT code 76000 is bundled into CPT code 0054T

Under Correspondence Language Policy/Example Number 14.0000T – Misuse of column two code with column one code, a new example is added:

For example, CPT code 0075T describes open or percutaneous transcatheter placement of an extracranial vertebral artery stent in an initial vessel and includes radiologic supervision and interpretation. CPT code 77012 describes computed tomographic guidance for needle placement including radiologic supervision and interpretation. It is a misuse of CPT code 77012 to report radiologic guidance or supervision and interpretation for the procedure described by CPT code 0075T. Therefore, CPT code 77012 should not be reported with CPT code 0075T.

HCPCS Level II Codes A0000-V9999

Under Correspondence Language Policy/Example Number 11.A-V – Anesthesia service included in surgical procedure, a new example is added:

CPB : Online Medical Billing Course

For example, if the physician performing low dose rate (LDR) prostate brachytherapy (HCPCS code G0458) also provides anesthesia for the procedure, the anesthesia service is not separately reportable. Therefore CPT code 00860 (anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; not otherwise specified) is bundled into HCPCS code G0458.

Use this information to offer guidance to providers when a Correspondence Language Example Identification Number (CLEID) is referenced in a response from a Medicare contractor.

Renee Dustman

Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.
Renee Dustman

About Has 607 Posts

Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

One Response to “Identify Code Edits Before They Hold Up Claims”

  1. tyhesia Moore says:

    Is ok for a coder to change an ICD-10 as long as it is in the patient medical records

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