Be Back Next Week

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I’m really trying to adjust to this “new normal” along with everything else that’s going on right now.

Taking a mental break and working in the garden.

Blog you next week.

Stay safe, healthy, and strong.

 

NCCI Edits

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During an audit of a surgical group, I found a large number of services were incorrectly reported with either 25, 59, XE, XS, XP, or XU modifier.

During my discussion with the coders, I discovered, in most cases, the coders were correctly using the modifiers, but billers were incorrectly adding the modifiers when claims were denied for unbundling.

First issue:  Providers should not allow billing services to add modifiers to “override” NCCI edits unless the billing service utilizes coders to review the documentation, and if supported, append appropriate modifiers.

Second issue:  If the documentation did not support separate and distinct services, the coders should not have reported both services with or without a modifier.  The claim would not have been denied as unbundling, and the billing company would not have appended an inappropriate modifier.

According to CMS’ National Correct Coding Initiative (NCCI), “The purpose of the NCCI Procedure-to-Procedure (PTP) edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table have been combined into one table and include PTP code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual”.

So, incorrect code combinations should not be reported.  You can download the zip file on CMS’ site, but let me save you some time.

Here are links to interactive NCCI lookup tools provided by a couple of the Medicare carriers.  The lookup tools are easy to use and give the same information as the zip file on the CMS website.

First Coast Service Options, Inc.

CGS

Always remember, even if the NCCI edit shows that two codes may be reported together, the documentation must support that the services were separate and distinct.

For example, to appropriately append the “X” modifiers, the documentation must show that it was:

XE – Separate encounter

XS – Separate Structure

XP – Separate Practitioner

XU – Unusual Non-Overlapping Service

The 25 – modifier appended to an evaluation and management code when reported in addition to a minor procedure will allow payment for the E/M service, but is it appropriate?

If the E/M service is documented as significant and separately identifiable and unrelated to the decision to perform the minor procedure, then it is correct to report the E/M service with modifier 25.

So, bookmark one of the interactive lookup tools to save time.  Understand that even though a modifier may be appropriate, the documentation must support the code combination and the modifier.

 

 

Honor. Remember. Never forget.

 

 

 

OIG 2020 Active Work Plan Items

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In OIG Exclusions List and Corporate Integrity Agreements and OIG Criminal and Civil Enforcement Updates, I shared cases and actions taken by the Office of the Inspector General because they presented opportunities to discuss the importance of compliance and identify potential areas of vulnerability in your own practices.

Here is a link to the OIG 2020 Work Plan.

“The OIG Work Plan sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by OIG’s Office of Audit Services and Office of Evaluation and Inspections. Projects listed in the Work Plan span the Department and include the Centers for Medicare & Medicaid Services (CMS), public health agencies such as the Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH), and human resources agencies such as Administration for Children and Families (ACF) and the Administration on Community Living (ACL)”.

I highlighted some items from the workplan.  These items present opportunities to be proactive in assessing your risk for an audit, providing education to your providers and coding staff, and creating compliance plans for more focused audits.

Report OEI-02-18-00380: Assessing Inpatient Hospital Billing for Medicare Beneficiaries

The results of this analysis will identify target hospitals or codes to review for incorrect codes.

Report W-00-20-35844: Medicare Part B Payments to Physicians for Co-Surgery Procedures

This audit will determine if Part B payments to providers for co-surgeries were properly made.  The audit will focus on claims submitted with modifier -62.

Report W-00-19-35827: Medicare Part B Payments for Speech-Language Pathology

This focus is on identifying potentially unallowable speech therapy services billed with KX modifier.

I review the workplan to identify opportunities for focused audits for my clients, and when performing the audits, this is my mental checklist:

• Does the documentation support the services billed?
• Does the documentation support the medical necessity of the services performed?
• Are services rendered by credentialed providers?
• Should services be billed under the non-physician practitioner instead of the physician?
• Is the billing system capable of tracking changes made post charge entry?
• If providers code their own services, is there a system in place to validate the codes?

The OIG workplan is updated regularly.  Be sure to bookmark the site and check for updates.