Internal Medicine Coding Alert

Published on Thu Feb 08, 2007 PDF

Check out the new edition of edits to see if your practice will be affected

The latest edition of the National Correct Coding Initiative (NCCI) instituted over 9,000 changes, so it’s time to get out your code lists and find out whether any of NCCI’s version 13.0 bundles will affect your practice’s bottom line.

Vent Management Codes Take a Hit

The new edition of NCCI will bar you from billing the new vent management codes (94002-94005) with most E/M codes.

But this shouldn’t surprise most internal medicine coders because the 2006 vent management codes (94656 and 94657) were already bundled into most E/M services, with no chance to override using a modifier.

The new edits simply reflect a change in CPT codes for vent management, with 94656 and 94657 being deletedin 2007 in favor of the new codes, 94002-94005. However, the new bundle is in line with the way coders reported vent management and E/M codes together in the past, says Stephanie Burnett, CPC, coder at Norton Community Medical Associates in Louisville, Ky.

Look for New Rules on Nursing Facility Edit

NCCI 13.0 deletes edits that bundled 14 E/M codes into initial nursing facility care codes 99304-99306. Unfortunately, it also changes the modifier status on edits that bundled another 49 E/M codes into 99304-99306. Previously, you could use a modifier to bill those E/M codes with 99304-99306, but now you can’t.

Although CPT states that all E/M services provided by the physician in conjunction with the nursing facility admission are considered part of the initial nursing facility care, it does not mention E/M services outside of the nursing facility visit.

Suppose your physician sees a patient for an office visit and for nursing facility care in the same day. In the past, your coder could report 99304 (Initial nursing facility care, per day ...) for the admission, along with 99213-59 (Office or other outpatient visit for the evaluation and management of an established patient; Distinct procedural service) for the office visit. However, you can no longer report the established patient E/M code because the NCCI bundles it into 99304, and no modifier can separate the two.

Prepare for Medically Unlikely Edits

Coders have heard rumors for several years about “medically unbelievable” or “medically unlikely” edits, but this time, CMS has gone ahead and instituted the new medically unlikely edits (MUEs).

Effective for dates of service on or after Jan. 1, 2007, you’ll have to contend with the MUEs, which are separate from the already-established NCCI edits -- but if the edits function as intended, you should find them more a help than a hindrance to your practice.

Bone Up on the New MUEs

The goal: The new edits are designed to prevent overpayments caused by gross billing errors, usually as the result of clerical or billing system mistakes, said Niles Rosen, medical director for Correct Coding Solutions, which has worked with CMS to develop the current edits, during a presentation at the American Medical Association’s CPT and RBRVS 2007 Annual Symposium in Chicago.

What it means to you: “The MUEs will limit automatically the number of units of service you can bill for a service in any 24-hour period,” Rosen said.

Learn Anatomical Edits First

The first batch of MUEs will focus on anatomically impossible claims, and CMS will phase in other edits over time.

For example: The MUEs would limit the number of simple repair codes (12001-12021) per anatomic location that you may bill per claim. For instance, you would never code for simple repairs of the hand using both 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) and 12004 (... 7.6 to 12.5 cm) for the same patient during the same session. Instead, you would add the lengths of the various repairs and report a single unit of service, such as 12004 (7.6 to 12.5 cm) or 12005 (... 12.6 to 20.0 cm).

Also, the edits will limit the claims for 99304 (Initial nursing facility care, per day ...) to a single unit per calendar day. This makes sense because 99304 is a “per day” code, experts say.

Appeal MUE Denials in These Cases

One advantage of the MUEs is that if you do run afoul of the edits, you won’t face denial for your entire claim but only the single line item that violates the MUE guidelines, Rosen said.

In addition, you will be able to appeal MUE rejections if you think your claim meets the requirements of medical necessity

Bonus: “We have designed the edits such that there should be an absolute minimum of inappropriately rejected claims. The criteria we use are meant to catch egregious errors, not to prevent legitimate services from being paid,” Rosen said.

Updates: Like the NCCI edits, MUEs will be updated quarterly and be subject to continuing refinement.

For more information on the MUEs, visit www.cms.hhs.gov/MLNMattersArticles/downloads/MM5402.pdf.