No CCI Edit Tool given to this Surgery Coder-Compliance Issue?

abazcoder

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Is it against any Compliance guidelines to NOT be using a CCI Edit checker tool? My new Manager is dragging her feet on getting us set up with one and I'm very nervous about not being able to check bundling, MUE's, and the like with my coding.
Aside from the hassle this is going to cause our Billers on the back end in the way of denials and confusion over what we can fight for and what we can't. Is there any hard and fast Compliance rule that states that a Coding Department has to use a CCI Edit tool?
 

mandymmathison

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I don't think there is guidance stating you must use a tool but I am still studying. There is guidance on unbundling and correct coding if that's what's or what's not happening. However CMS's edits are accessible to everyone on their NCCI website. It's not as easy as a tool and you have to read but all your NCCI edits, MEUs, add on code edits are all in one place. It took me time to learn them but I trust this more than the tool. Also if you have access to insurance portals some include what is sometimes called clear claim connection based on their rules. https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
 

Pam Brooks

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It is against Medicare regulations to unbundle. Many commercial payers also follow NCCI. Whether you use a CCI checker, or do it manually through reveiw of the NCCI excel spreadsheets and reveiw of the IOMs, if you are recipients of Medicare dollars, you are expected to bill appropriately. This is in violation of the False Claims Act, and there are multiple program integrity issues when you bill outside Medicare guidance. The Centers for Medicare & Medicaid Services (CMS) says that “[m]isusing codes on a claim, such as upcoding or unbundling codes” are unethical billing practices. CMS clarifies that not only are these practices unethical, but they “can also expose providers to criminal and civil liability.” Something that is unethical is not necessarily illegal, but it is in this context.

Your new manager needs some coding education. Otherwise she may need an attorney. Tell her I said so.
 

Orthocoderpgu

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I know your manager is "looking at the money" which is why they are dragging their feet. But the thing that they don't understand is that encoders pay for themselves in productivity. Can you look things up without an encoder? Sure, but it will take you forever and you won't get anything done at the end of the day. I second the information that Pam has said, this needs to be a priority.
 

abazcoder

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I don't think there is guidance stating you must use a tool but I am still studying. There is guidance on unbundling and correct coding if that's what's or what's not happening. However CMS's edits are accessible to everyone on their NCCI website. It's not as easy as a tool and you have to read but all your NCCI edits, MEUs, add on code edits are all in one place. It took me time to learn them but I trust this more than the tool. Also if you have access to insurance portals some include what is sometimes called clear claim connection based on their rules. https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
Thank you for your response. I know of the CMS Edit lookup, but it's been many years since I've had to go that route to look up codes. Thank you for sending the link, but my next question is, exactly where is the actual tool (or spreadsheet) within the page you sent me? There are so many links to other pages within CMS and so far I'm not finding the actual CCI Edit lookup sheet anywhere. I appreciate your trying to help me with this :)
 

abazcoder

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It is against Medicare regulations to unbundle. Many commercial payers also follow NCCI. Whether you use a CCI checker, or do it manually through reveiw of the NCCI excel spreadsheets and reveiw of the IOMs, if you are recipients of Medicare dollars, you are expected to bill appropriately. This is in violation of the False Claims Act, and there are multiple program integrity issues when you bill outside Medicare guidance. The Centers for Medicare & Medicaid Services (CMS) says that “[m]isusing codes on a claim, such as upcoding or unbundling codes” are unethical billing practices. CMS clarifies that not only are these practices unethical, but they “can also expose providers to criminal and civil liability.” Something that is unethical is not necessarily illegal, but it is in this context.

Your new manager needs some coding education. Otherwise she may need an attorney. Tell her I said so.
Hi Pam,
Thank you so much for your thorough reply. You voiced my sentiments exactly.
 

mandymmathison

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Thank you for your response. I know of the CMS Edit lookup, but it's been many years since I've had to go that route to look up codes. Thank you for sending the link, but my next question is, exactly where is the actual tool (or spreadsheet) within the page you sent me? There are so many links to other pages within CMS and so far I'm not finding the actual CCI Edit lookup sheet anywhere. I appreciate your trying to help me with this :)
They're all over the place but if you Google and familiarize yourself it will get easier over time. If you click the edit you're looking for the spreadsheets are usually linked at the bottom. Like I said a tool is great but I've found info in these our tools didn't have. Like exactly what qualifies for specific modifier usage instead of just telling you, you can use one to override an edit. If you're only dealing with a certain set of surgeries you can start putting together your own tools. Like stated above it is against compliance to code incorrectly and unbundle. However, some businesses hire coders expecting them to have their own knowledge and tools. Others provide them everything.
 
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