How to Make Sense of the 2019 First Quarter NCCI Edits

Posted on 25 Jan, 2019 |comments_icon 0|By Bruce Pegg
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If you shook your head in disbelief at the last round of National Correct Coding Initiative (NCCI) edits, you’re probably not alone. That’s because the Centers for Medicare and Medicaid Services (CMS) created a staggering 45,727 additions, 19,729 deletions, and 41 changes to the list when it released the latest quarterly round of edits effective Jan. 1, 2019.

But before we look at some of the specific changes that will affect your coding during the first quarter of 2019 and beyond, a quick reminder about why we have NCCI edits and how they work is in order.

What are the NCCI Edits, and Why Edit Pairs?

The NCCI edits are a series of procedure-to-procedure, or PTP, edit pairs. CMS creates the pairs for numerous reasons but understanding two of them will help you fully understand the reasons behind CMS’s decision to pair up specific services and procedures.

The first reason is that CMS believes that one procedure (designated as the column 2 code) is, in part or completely, included in another procedure (the column 1 code). As an example, 30110 (Excision, nasal polyp(s), simple) and 30115 (Excision, nasal polyp(s), extensive) are both considered bundled into 30160 (Rhinectomy; total) as polyp removal is regarded as an integral part of a rhinectomy.

CMS also creates PTP edit pairs when they believe two procedures cannot be performed on the same anatomic site or that two encounters cannot occur at the same time. These are known as mutually exclusive edits, and you can see one example at work in the hospital care codes. Here, you cannot bill 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient) as a column 2 code with an initial hospital care code such as 99221 (Initial hospital care, per day, for the evaluation and management of a patient …) on the same day, simply because, by definition, a hospital stay is either initial or subsequent but never both.

Modifier Indicators Point the Way to Pay

Once CMS creates a PTP code pair, it assigns one of the following correct coding modifier indicators (CCMI) to the pair:

  • 0 (Not allowed) means that there are no circumstances in which a payer will pay for both procedures when the same provider performs them on the same day for the same beneficiary. Consequently, you cannot use a modifier to unbundle this PTP code pair, and payers will only pay for the column 1 code if you attempt to report the pair together.
  • 1 (Allowed) means that modifiers associated with NCCI are allowed with the PTP code pair when appropriate. Use of the correct modifier will unbundle the pair, and your payer will then pay for both codes.
  • 9 (Not applicable) means that the edit pair is currently inactive as of the last round of edits, and an NCCI-associated modifier is not needed to unbundle the PTP code pair at this point in time.

The modifiers you need to know. To receive payment for the column 2 code, appropriate modifiers include modifier 59 (Distinct procedural service) in the case of procedures, modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) in the case of evaluation and management (E/M) services, or a Level II modifier, such as E1 (Upper left, eyelid), when procedures are distinct due to anatomical location.

To download the full, current National Correct Coding Initiative Policy Manual for Medicare Service, go here.

1 New Code, Many CCI Edits

Clearly, we don’t have the time or space here to go through each edit in the latest quarterly round. But one new code that goes across specialties, and that may well affect your practice, is 99491 (Chronic care management services …). In the 2019 first quarter CCI edits, this has become a heavily featured column 1 code in numerous PTP pairs. Among the column 2 codes that now have a 0 modifier with 99491 are the patient self-management codes (98960-98962) and the non-face-to-face nonphysician service codes (98966-98969).

Additionally, CCI adds numerous E/M services as column 2 codes with a 0 modifier, including prolonged E/M services (99358/+99359), medical team conferences (99366-99368), care plan oversight services (99374-99380), non-face-to-face services (99441-99444), care management services (99487-99491), and transitional care management services (99495-99496).

The exception: Code 99487 (Complex chronic care management services …) is not listed as a column 2 code with 99491. Why this is so remains a mystery, but as 99487 includes the criteria for 99491, it would be redundant, and certainly inappropriate, to report both codes together.

So, What’s Going to Be in Your Wallet in 2019?

If you want to make sense of the CCI edits that affect your coding, go through your 2019 CPT® manual and identify all the new CPT® codes that you anticipate using this year – that is, if you haven’t done so already. Then download the zip file “Quarterly Additions, Deletions, and Modifier Indicator Changes to NCCI edits for Physicians/Practitioners … Effective January 1, 2019” and search for those codes in the downloaded Excel file. Doing so will help you head off denials at the pass, and help your practice move profitably and smoothly through the new year and beyond.

Learn More

Stay informed of CCI edits — and so much more — with your risk-free subscription to Primary Care Coding Alert. Every issue of this monthly newsletter delivers coding and billing guidance, as well as high-impact tips and strategies to conquer the revenue-risking challenges that threaten your claims and compliance success.

Author

Bruce Pegg
Editor, Newsletters

An experienced teacher and published author, Bruce is TCI’s new voice of primary care, delivering advice and insights every month for coders in the fields of family, internal, and pediatric medicine through Primary Care Coding Alert and Pediatric Coding Alert. Additionally, he is the current editor of E/M Coding Alert. Bruce has a Bachelor of Arts degree from Loughborough University in England and a Master of Arts degree from The College at Brockport, State University of New York. He recently became a Certified Professional Coder (CPC®), credentialed through AAPC.

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