Medicare s National Correct Coding Initiative (CCI)

Transcription

1 Medicare s National Correct Coding Initiative (CCI) Mark S. Synovec, MD, FCAP Topeka Pathology Group, Inc. Topeka, Kansas College of American Pathologists Materials are used with the permission of Mark S. Synovec, MD, FCAP. 1

2 Course Objectives Clearly understand the origin, evolution and purpose of the CCI. Be able to apply CCI principles to coding and billing activities. Know the role of specialty societies and CAP advocacy efforts in the CCI process. 2

3 History Pre-1996 ever growing use of Black Box Edits National outcry from physician abhorring BBE s CMS response: RFP for a vendor to provide publicly known edits. NCCI becomes a reality

4 Purpose of CCI The National Correct Coding Initiative (NCCI or CCI) was developed by the Centers for Medicare and Medicaid Services (CMS) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Medicare Part B claims. 4

5 How is the CCI Managed? CCI is administered by AdminaStar Federal, Inc. (a subcontractor of Reliance Safeguard Solutions) an Indianapolis-based federal contractor that develops and refines the CCI, however; CMS owns CCI and ultimately makes all decisions about its content. 5

6 What are CCI Edits? CCI edits are pairs of CPT or HCPCS Level II codes that are not usually separately payable. The edits apply to services billed by the same provider for the same patient on the same day. 6

7 How are CCI Edits Arranged? The edits are arranged by two sets of tables. One table contains the Column 1/ Column 2 Correct coding edits (formerly known as Comprehensive/Component edits). The other table contains the Mutually Exclusive edits. 7

8 How are CCI Edits Arranged? CORRECT CODING EDITS FOR CODES Col. 1 Col , , ,

9 What are Column 1/Column 2 Correct Coding Edits? Column 1/Column 2 Correct Coding Edits contain two types of code pair edits. One type contains column 2 codes which are an integral part of column 1 codes. The other type contains codes that should simply not be reported together for other reasons (e.g., misuse of the code, etc). 9

10 What are Mutually Exclusive Edits? Mutually exclusive codes represent services that cannot reasonably be performed in the same session by the same provider on the same patient. 10

11 What Do the Superscript Numbers Mean? The 0 indicator means that no CCI associated modifiers are allowed with the edit pair. The 1 indicator means that CCI associated modifiers are allowed with the edit pair. The 9 indicator is used only on those code pairs that have been deleted where the deletion date was retroactive to the effective date. 11

12 What Modifiers are Allowed with CCI Edits? -59 Distinct Procedural Service Under certain circumstances the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances... 12

13 What Modifiers are Allowed with CCI Edits? (cont.) -91 Repeat Clinical Diagnostic Laboratory Test In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the modifier 91 13

14 What is the Role of Organized Medicine? American Medical Association (AMA) formed the Correct Coding Policy Committee (CCPC) in 1995 to provide formal input into NCCI process. CCPC has largely become a virtual committee with a single role of disseminating quarterly proposed edits. Any coordinated oversight of the NCCI by the CCPC is lacking. NCCI also notifies societies individually of proposed edits. 14

15 How Often are CCI Edits Updated? CCI edits are updated on a quarterly basis. Varying number of changes in every update. Obtain each version update to effectively and efficiently manage coding practices. 15

16 How Big of an Issue Is It? Currently NCCI includes more than 140,000 CPT code pairs, or "edits," that generally cannot be used on a single Medicare claim. Over 600 of these include services in the CPT series. Over 100 of these includes services in the CPT series (anatomic pathology). 16

17 Trends with NCCI The house of pathology and other specialties have sensed a progressive realignment of NCCI from correct coding tool to enact a new payment policy. There has been less responsiveness of AdminaStar to accept CAP recommendations regarding proposed coding edits. 17

18 CAP Concerns with CCI Weight given to comments by knowledgeable specialties versus anecdotal non-disclosed practitioners; Access to utilization data used in the decision-making process is not provided; Openness of the process lacking; 18

19 CAP Concerns with CCI (cont.) When College opinions are not accepted meaningful explanations are not received. Used Car Salesman approach is sometimes encountered. Lack of opportunities to appeal final edit decisions. CPT solutions to NCCI problems come slowly. 19

20 CPT-Physician s Current Procedural Terminology: Code Time Table Best case Worst case January 3, 2003 CPT proposal submission deadline October 6, 2003 April 1, 2003 CPT panel agenda books mailed January 6, 2004 May 1, 2003 CPT panel meets February 5, 2004 August 13, 2003 RUC preparation February 11, 2004 September, 2003 RUC meeting April 22, 2004 January 1, 2005 Adopted for CPT 2005 & 2005 January 1,

21 The 88180/ Edit Story Aug. 19, 2002 Received notice from CMS of intent to add edit to CCI. If the evaluation of a patient s specimen includes testing by flow cytometry (88180) and immunocytochemistry (88342) for the same cellular characteristic (e.g. CD3), only one type of testing should be reported. 21

22 The 88180/ Edit Story (cont.) Oct. 8, 2002 CAP submitted letter of protest to CMS. it is not uncommon for immunohistochemistry to be clinically indicated in addition to flow cytometry in many instances, the morphology may indicate a need for both flow and IHC to be performed 22

23 The 88180/ Edit Story (cont.) Oct. 30, 2002 CMS replied: CMS will implement this edit in NCCI version 9.0 scheduled for January 1, 2003 The edit is necessary to address incorrect coding where providers are billing for duplicative testing 23

24 The 88180/ Edit Story (cont.) when a battery of tests billed as and a battery of tests billed as yield the same diagnosis when the provider performs tests for the same markers (e.g. CD3 or CD20) by both technique and technique. 24

25 The 88180/ Edit Story (cont.) Jan. 15, 2003 CAP submitted 2 nd protest letter to CMS. It is not uncommon for immunohistochemistry to be necessary even though flow cytometry is performed. For, example, the pathologist receives a lymph node and submits it for flow cytometry which is negative. The histology shows a small population of larger cells that not uncommonly do not survive flow processing. In this case, a provider would require immunohistochemistry to confirm large cell lymphoma or Hodgkin s disease. 25

26 The 88180/ Edit Story (cont.) Feb. 25, 2003 CMS replied: This edit addresses a practice among some providers to commonly perform both and testing on the same specimen when there is no specific indication for doing so. 26

27 Interim Options Options to address concerns or develop new CPT codes and values can take up to two years. Temporary G codes are an option to reduce time period. 27

28 What are G Codes? G codes are temporary level II HCPCS, used to identify professional health care procedures and services that would otherwise be coded in CPT but for which there are no CPT codes. 28

29 How are G Codes Assigned? Typically, CMS utilizes G codes to accommodate changes in legislation, regulation, coverage and payment policy and routinely includes G codes in the final Medicare physician fee schedule rule to address concerns of the agency. 29

30 How are G Codes Paid? G codes and corresponding payment do not go through the review process utilized to establish CPT codes and corresponding relative value units (RUC). 30

31 CAP Advocacy Efforts Regularly reviews and submits comments on proposed CCI edit additions, modifications and deletions. Sept. 8, 2003-Met with CMS officials to discuss the CCI process. Oct. 3, 2003-Met with CMS Administrator Tom Scully to discuss unfair payment denials and CCI process. 31

32 CAP Strategic Considerations Has the evolution of the NCCI process maintained its legal responsibilities to CMS for provider input? Should the AMA-CCPC be re-energized to give a higher level of oversight into the NCCI process? Who should be in charge of the correct use of CPT? 32

33 CAP Strategic Considerations (cont.) AMA HoD Resolution 709: NATIONAL STANDARD FOR CODE COMBINATIONS RESOLVED, That our American Medical Association study and report back to the House of Delegates on the feasibility of developing a national standard for the utilization of codes, code combination, and modifiers that is consistent with all CPT codes, guidelines, and conventions, and that would be used by all commercial and governmental payers. 33

34 Anatomic Pathology CCI Edits that You Should Know! 88112/ / / / / / / / / / / / / / / /

35 Anatomic Pathology CCI Edits that You Should Know! / / / / / / / / / / / /

36 Assistance with CCI National Correct Coding Initiative AdminaStar Federal, Inc. P.O. Box Indianapolis, IN Attention: Niles R. Rosen, MD or Linda Dietz Fax to (317)

37 Assistance with CCI College members who have specific concerns about CCI edits should contact the College's Washington Office, at (800) ext or at 37

38 Additional Resources CMS has posted a National Correct Coding Initiative page on its web site, listing all current edits from version 9.2 of the CCI. The page also list links to other relevant CCI information. 38