Billing errors for a suite of heart procedures cost American hospitals millions of dollars a year, according to a report from the Health and Human Services’ Officer of Inspector General (OIG), and the NCCI could be to blame. If your facility is confused by coding heart catheterizations and heart biopsy coding, you’re not alone.
Report Highlights the Reason for the NCCI
The report, issued this year, looked at billing data from 2011 and 2012. “Hospitals nationwide generally did not comply with Medicare requirements for billing outpatient right heart catheterizations and heart biopsies provided during the same patient encounter, resulting in estimated overpayments of $7.6 million over approximately 2 years,” according to the report.
It was with such errors in mind that the Centers for Medicare & Medicaid Services (CMS) created the National Correct Coding Initiative.
NCCI aims to prevent the incorrect payment of procedures that should not be billed together, and includes physician edits and outpatient edits, each of which are divided into code pairs to identify unbundled series and mutually exclusive code pairs. Often called “Column One/Column Two edits,” the guidelines are just that—a spreadsheet with associated codes in two columns. “When two edited codes are billed together, only the code in Column One will be reimbursed. The code in Column Two will be denied,” explained the APA Practice Association.
Coding Help Can Also Cause Confusion
While NCCI was meant to solve problems, it can create confusion, too. CMS and private insurers may have different payment rules and bundling packages, noted Healio. “Private insurers often use a mixture of NCCI and proprietary payment systems[;] however providers and billing/coding specialists may not realize these differences exist and there are available opportunities from knowing those differences,” said Dr. William R. Beach.
Elsewhere, NCCI edits can cause bellyaches, too. The American Academy of Family Physicians complained years ago that a previous iteration of the NCCI made it difficult for physicians and other care providers to “bill for administration of immunizations in conjunction with well-child visits,” meaning that “with the NCCI edits, CMS effectively undermined years of progress on the immunization front by severing the connection between well-child checkups and immunizations.”
NCCI Edit Fails Hospitals
Back to the issue of heart biopsies, the OIG said, “Hospitals nationwide complied with the Medicare requirements for billing outpatient RHCs and heart biopsies provided during the same patient encounter for 8 of the 100 sampled line items,” the agency said in a report. That means “the hospitals did not comply with the Medicare requirements for 92 of the 100 sampled line items”—not a great statistic for hospitals.
While the OIG pointed to use of the NCCI as one way to stop the hurt, it also said hospitals weren’t doing it right: “Typically, an NCCI edit would prevent the payment for a right heart catheterization (RHC) when billed on the same claim as a heart biopsy. However, under certain circumstances, a hospital may bill and get paid for both services in an NCCI code pair by including a modifier on the claim. If a hospital included modifier -59, it would bypass the NCCI edit and receive payment for both procedures as though they were performed separately.” And that’s the error: “A hospital should not append modifier -59 to the HCPCS code representing an RHC when it is performed with a heart biopsy unless the procedures are separate and distinct.”
It’s hard to blame hospitals, as the NCCI gets updated all the time and seemingly without warning.
The NCCI is updated quarterly, and CMS has a helpful and detailed FAQ section on its website. But CMS notes that changes to the NCCI may be reversed from one edition to the next. “Changes in the National Correct Coding Initiative (NCCI) are the result of comments submitted to CMS via Correct Coding Solutions LLC and CMS’s written or telephone correspondence,” CMS said. “Sometimes, new information is provided by a commenter which changes CMS’s decision about the edit.”
Also, CMS’s tutorial for using NCCI is updated only about once a year. In the current edition, the tutorial cautions that the NCCI “does not include all possible combinations of correct coding edits or types of unbundling that exist.”
Solve the Problem by Staying Educated
Physicians, coders, billers and managers—especially those who specialize in surgery—can stay up to date by joining coding and reimbursement expert Kim Garner-Huey’s ProfEdOnDemand seminar “Understanding the NCCI Edits and 2017 Q4 Updates.” Garner-Huey will review the October 2017 updates to NCCI edits, give instructions for accessing NCCI guidelines, explain coding guidelines, help you gain confidence in appropriate modifier use, and give hints for coping with medically unnecessary denials.
