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Back in 1996, the Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote correct coding and prevent inappropriate payment of Medicare Part B claims. As this is an automated prepayment review by CMS, the NCCI edits reduce payment error by identifying coding errors made by providers. In 2009, 7.8 % of Medicare dollars did not comply with one of more Medicare coverage, coding, billing or payment rules, translating into $24.1 billion dollars in Medicare overpayments and underpayments annually. The NCCI edits define when two HCPCS/CPT® procedure codes may not be reported together except under special circumstances. The Centers for Medicare & Medicaid Services (CMS) based the NCCI coding policies on current coding conventions, coding guidelines, national and local Medicare policies (NCDs and LCDs), and standard medical and surgical practice. Coding polices and guidelines require that procedures are reported with the most comprehensive CPT® code that describes the services performed. For example, a coder should not report a Basic Metabolic Panel (BMP, CPT® 80047) with a Comprehensive Metabolic Panel  CMP,CPT® code 80053) as all the analytes in CPT® 80047 BMP are a subset of the Comprehensive Metabolic Panel and would have been already performed as part of that procedure. As a claim is processed by the Medicare contractor, the system tests every pair of procedure codes to determine if they comply with the NCCI edit policy. This means every code pair reported for the same date of service for the same beneficiary by the same provider is reviewed against the NCCI-edit tables. If a pair of codes on the claim  matches (“hits”) a pair in the NCCI edit table, the “Column Two” code of the edit pair is denied for payment. Using the CMP/BMP example above, in the NCCI edit tables, CPT® 80047 is the “Column Two” code and would have payment denied. NCCI-associated modifiers are used to indicate the special circumstances such as when the procedures are performed at different anatomic sites, a separate procedure or repeat clinical diagnostic laboratory test. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together. NCCI-associated modifiers may not be used to bypass an edit unless the criteria for use of the modifier are met. Each active NCCI edit has a modifier indicator of 0 or 1. A modifier indicator of “0” indicates that an edit can never be bypassed even if a modifier is used. In other words, the Column 2 code of the edit will be denied. A modifier indicator of “1” indicates that an edit may be bypassed with an appropriate modifier appended to the Column 1 and/or Column 2 code. The NCCI-associated modifiers are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, 25, 27, 58, 59, 78, 79, and 91. In January 1, 2013, additional modifiers were added to the list of NCCI-associated modifiers that will allow an edit to be bypassed when the modifier is used correctly (i.e., edits with modifier indicator of “1”). These were LM (left main coronary artery), RI (ramus intermedius), 24 (unrelated evaluation and management service by the same physician during a postoperative period), and 57 (decision for surgery). Effective Jan 15, 2015, new more specific modifiers  become effective (see also Compliance Matters, Sept 2014) supplementing Modifier -59 (Distinct Procedural Service). XE Separate Encounter: A Service That Is Distinct Because It Occurred During A Separate Encounter XS Separate Structure: A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure XP Separate Practitioner: A Service That Is Distinct Because It Was Performed By A Different Practitioner XU Unusual Non-Overlapping Service: The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier. CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. Services denied based on NCCI edits may not be billed to Medicare beneficiaries, nor can a provider use an “Advanced Beneficiary Notice” (ABN) to seek payment from the patient since these denials are based on incorrect coding rather than medical necessity or a benefit exclusion. Hospitals, like physicians and other providers, must follow national correct coding policies. Though the NCCI edits were initially developed for processing professional claims, the NCCI edits are incorporated into the Outpatient Code Editor (OCE) used for processing outpatient hospital service claims, outpatient physical therapy and speech-language pathology services, skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), and home health agencies (HHAs). These are commonly referred to as the NCCI “Hospital” Version of CCI edits. Review the NCCI manual on CMS here: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/

Since Medicare’s inception in 1966, private healthcare insurers have processed medical claims for Medicare beneficiaries. Originally these entities were known as Part A Fiscal Intermediaries (FI) and Part B carriers. In 2003 the Centers for Medicare & Medicaid Services (CMS) was directed via Section 911 of the Medicare Prescription Drug Improvement, and Modernization Act (MMA) of 2003 to replace the Part A FIs and Part B carriers with A/B Medicare Administrative Contractors (MACs) in accordance with the Federal Acquisition Regulation (FAR). A Medicare Administrative Contractor (MAC) is a private healthcare insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims. MACs perform many activities including: Process Medicare FFS claims Make and account for Medicare FFS payments Enroll providers in the Medicare FFS program Handle provider reimbursement services and audit institutional provider cost reports Handle redetermination requests (1st stage appeals process) Respond to provider inquiries Educate providers about Medicare FFS billing requirements Establish local coverage determinations (LCD’s) Review medical records for selected claims Coordinate with CMS and other FFS contractors Currently there are 12 A/B MACs and 4 DME MACs in the program that process Medicare FFS claims for nearly 70% of the total Medicare beneficiary population, or 37.5 million Medicare FFS beneficiaries. The MACs serve more than 1.5 million health care providers enrolled in the Medicare FFS program. Collectively, the MACs process more than 1.2 billion Medicare FFS claims annually, 210 million Part A claims and more than 1 billion Part B claims, and paid $367 billion in Medicare benefits. MAC A/B Jurisdiction Map (March 2023):   Source: www.cms.gov

Did you know that it costs an average of $25 to rework a single claim?  It’s true, according to a recent Health IT News article. The article goes on further to state that as many as 65 percent of denied claims remain unresolved because they are too costly to rectify. These unpaid claims eventually become lost revenue. Experian Health’s Denials Workflow Manager and Enhanced Claim Status solutions are part of an integrated revenue cycle platform for healthcare providers to manage payer billing and payment processes.  Effective management of these processes directly results in improved cash flow, lower days in A/R, and more efficient operations. Clients converting to our integrated claims and denial solution are experiencing a 50% increase in clean claim rates and faster turnaround on cash. Learn more by visiting our Claims Management page or reserve your spot at one or both of our Claims sessions at the upcoming HFMA ANI conference: June 27 | 1:30pm | Manage Denials to Maximize Reimbursement, Revenue and Cash Flow June 28 | 9:45am | Claims Management

Experian Health has launched Coverage Discovery® on demand, which is integrated into Epic’s EMR. We are the first-to-market with this functionality for Epic. In addition to Coverage Discovery’s batch reclassification of uncompensated care by finding previously misidentified patient coverage across both government and commercial payers by using advanced analytics, multiple data sources and a proprietary coverage optimization engine, the “on demand” feature provides Epic clients with additional opportunities to find coverage early in the revenue cycle—reducing additional downstream processes. By adding the on demand option, Experian Health’s clients can now run Coverage Discovery within their Epic workflow, which will help to reduce errors, save time and ultimately improve their revenue cycle. Every dollar found in our proactive, automated Coverage Discovery solution is a dollar that our clients are not spending pursuing patients for payment, paying for expensive collection agencies, or writing off to bad debt. Coverage Discovery is also available via eCare NEXT®, OneSource and Batch for non-Epic users. Coverage Discovery is providing significant results for over 300 Experian Health clients. In 2015, the solution discovered coverage associated with over $1.1 billion in charges. According to Murry Ford, Director, Revenue Strategy at Grady Health System, “Coverage Discovery consistently delivers value to our organization. Since our June 2015 go-live of the batch product and November 2015 go-live of the on demand product, Coverage Discovery has protected $2.3 million in reimbursement, $509,000 of which resulted from Coverage Discovery on demand queries for inpatient admissions over a two month period.” Read our latest press release, which further highlights Grady’s success using this solution.

Welcome Katie Zibelin, Experian Health Marketing’s newest team member. Katie made her Experian debut in August 2015 as an intern where she supported client events, tradeshows and proposal efforts behind the scenes.  Upon securing her advertising degree from the University of Texas at Austin in December 2015--one semester ahead of schedule--Katie joined the team full time this February. In her current role as a Marketing Coordinator, Katie is responsible for tracking projects, managing vendor activities, conducting tradeshow and vendor research, developing new vendor relationships, coordinating and supervising tradeshow activities and communicating programs and events. Katie also serves as the project leader of our 2016 Regional User Conferences. In her first solo performance at our Southeast Regional Conference in New Orleans, Katie received rave reviews for demonstrating project management and event planning maturity and grace under pressure. Fun Fact: Katie is also an accomplished contemporary dancer/performer/instructor. Please do not hesitate to reach out to Katie with questions regarding any of the upcoming Regional User Conferences at Katie.Zibelin@experianhealth.com.

Did you know? In 2015, Experian Health helped nearly 700 provider clients screen over 51 million patients for financial assistance. That’s important for healthcare providers that are ramping up to meet 501r regulation requirements this year. Experian Health’s Patient Financial Clearance automates the financial screening process prior to service or at the point of service, to determine if patients qualify for Medicaid, charity or any assistance program, while auto-enrolling eligible patients. This new solution can help you: Meet 501r regulatory requirements Increase staff productivity by expediting financial assistance decisions Improve point-of-service collections Reduce overall AR days Patient Financial Clearance uses a proven combination of consumer data, patient-provided information and provider policies to automate the screening process and empower patient access staff to be more productive and effective. Help your patients while protecting your bottom line. Contact us today at experianhealth@experian.com or 1 888 661 5657 to find out how Patient Financial Clearance can help you.

Screening for the Human Immunodeficiency Virus (HIV) infection On February 5, CMS released a change request to inform contractors that CMS has determined that the evidence is adequate to conclude that screening of HIV infection for all individuals between the ages of 15-65 years is reasonable and necessary for early detection of HIV and is appropriate for individuals entitled to benefits under Part A or enrolled in Part B. Effective date: April 13, 2015 Implementation date: March 7, 2016, for non-shared A/B MAC edits; July 5, 2016 for CWF analysis and design; October 3, 2016, for CWF Coding, Testing and Implementation, MCS, and FISS Implementation; January 3, 2017, for Requirement 9403.04.9 View Transmittal R3461CP View Transmittal R190NCD Screening for Cervical Cancer with Human Papillomavirus (HPV) testing On February 5, CMS released a change request stating CMS has determined that for dates of service on or after July 9, 2015, evidence is sufficient to add HPV testing under specified conditions. Effective date: July 9, 2015 Implementation date: March 7, 2016, for non-shared MAC edits; July 5, 2016, for CWF analysis and design; October 3, 2016, for CWF Coding, Testing and Implementation, MCS, and FISS Implementation; January 3, 2017, for Requirement BR9434.04.8.2 View Transmittal R3460CP View Transmittal R189NCD Revision to Fiscal Intermediary Shared System (FISS) lab travel allowance editing to include new specimen collection code G0471 On February 5, CMS released a change request updating FISS reason code 32436 to include HCPCS code G0471 in the list of specimen collection fee codes that will allow the travel allowance to be paid on outpatient claims. Effective date: April 1, 2016 Implementation date: July 5, 2016, for claims processed on or after View Transmittal R1619OTN View MLN Matters article MM9471

After five years of ICD-10 classification system code freezes, October 1, 2016 will see the system back on the routine cycle for annual updates. On March 9th and 10th, the ICD-10 Coordination and Maintenance committee met to review proposals for both ICD-10-CM and ICD-10-PCS. All PCS codes to date that have been approved as new, revised, and deleted have been compiled into a file for review under the Coordination and Maintenance Committee meeting materials. For the October 1, 2016 update, there are currently 75,625 PCS codes for the FY 2017 update, which includes 3,651 new codes and 487 revised code titles. Of the 3,651 new codes, 3,549 are cardiovascular system codes. These relate to unique device values, the addition of bifurcation as a qualifier, and additional specific body parts, as well as congenital cardiac procedures and placement of an intravascular neurostimulator. All of the revised code titles at this time have come from changing the number of coronary artery sites to the number of vessels, and the specification of the descending thoracic aorta. Additional new codes include the expansion of the body part detail in Removal and Revision of lower joints, and the addition of unicondylar knee replacement. The codes presented at this meeting were for implementation in October 2016 and will be added to the already-approved list There were 24 diagnosis proposals on the agenda for discussion such as: Clostridium Difficile: A proposal was presented to expand the code to differentiate recurrent C. difficile  enterocolitis from enterocolitis not specified as recurrent. Congenital sacral dimple: The American Academy of Pediatrics proposed a new congenital code so this condition can be accurately tracked. Myocardial infarction: Specify the types as defined by several professional cardiology organizations. A specific code was proposed for type 2 myocardial infarction due to demand ischemia or ischemic imbalance so that data can be captured. The additional myocardial infarction types (3, 4a, 4b, 4c, 5) would all be assigned to one ICD-10-CM code. There was much discussion on this proposal related to the code proposals as well as the indexing and impact on subsequent myocardial infarctions. This proposal was requested for inclusion in the 10/1/16 addenda. Zika virus was discussed, regarding a new code being created. NCHS/CDC is proposing it for inclusion in the 10/1/16 addenda which would be consistent with the World Health Organization’s ICD-10 update According to CMS, the coding update will be implemented on Oct. 1, 2016, and will include the “backlog of all proposals for changes to the code set proposed via the ICD-10 Coordination and Maintenance Committee process during the partial code freeze, and receiving public support.” The codes are posted on the Centers for Disease Control and Prevention National Center for Health Statistics website here: ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2017/NewICD10CMCodes_FY2017.txt Review the Meeting Agenda here: http://www.cdc.gov/nchs/data/icd/topic_packet_03_09_16.pdf

On February 26th, CMS published a One-Time Notification, Transmittal 1630, Change Request 9540. This change request (CR) is the 6th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs) with   implementation date of July 5, 2016 for all Medicare Contractors The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CR7818, CR8109, CR8197, CR8691, CR9087, and CR9252. Some are the result of revisions required to other NCD-related CRs released separately. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases as needed. No policy-related changes are included with these updates as any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process The NCD’s updated per this CR are listed below: NCD20.29 - Hyperbaric Oxygen Therapy NCD90.1 - Pharmacogenomic Testing for Warfarin Response NCD110.18 - Aprepitant for Chemotherapy-Induced Emesis NCD150.3 - Bone Mineral Density Studies (See also Medlearn Matters SE 1525 04/12/16) NCD160.18 - Vagus Nerve Stimulation for Treatment of Seizures NCD160.24 - Deep Brain Stimulation for Essential Tremor NCD210.3 - Colorectal Cancer Screening Tests NCD210.14 - Screening for Lung Cancer with Low-Dose CT NCD230.18 - Sacral Nerve Stimulation for Urinary Incontinence NCD260.1 - Adult Liver Transplantation NCD110.4 - Extracorporeal Photopheresis NCD20.33 - Transcatheter Mitral Valve Repair NCD220.13 - Percutaneous Image-Guided Breast Biopsy NCD220.4 - Mammograms Read the details of this direction here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2016-Transmittals-Items/R1630OTN.html?DLPage=1&DLEntries=10&DLFilter=R1630Otn&DLSort=1&DLSortDir=ascending