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cpb certified professional biller > Chapter 7 > Flashcards

Chapter 7 Flashcards

1
Q

Medical Necessity
is defined differently by different entities.

Health Ins only covers services they define as medically necessary.

A

Medicare will NOT cover services that are not reasonable and necessary for the treatment..

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2
Q

The AMA
American Medical Association Policy defines medical necessity.

LOMN: Letter of Medical Necessity

A

*Services/product a prudent physician would provide for the following:
*Preventing
*Diagnosing or treating IID (illness, injury disease)
A:
in accordance with (GAS) generally accepted standards of medical practice.
B:
clinically appropriate in terms of type, frequency extent, site and duration
C:
NOT for economic benefit of health plan, purchaser, convenience of patient, physician, or other provider.

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3
Q

NCD: National Coverage Determination
Medicare NCD

MAC releases LCD
Local Coverage Determinations

A

LCD will consider if an item/service is considered medically necessary.

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4
Q

NCCI: aka CCI
National Correct Coding Initiative is released by CMS to indicate codes considered to be …

NCCI/CCI
shortened to CCI.

A

bundled for procedures/services deemed necessary to accomplish a major procedure.

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5
Q

MUE (number of units)
Medically Unlikely Edits
are released by CMS to indicate …

A

the number of units that can be reported for a service/procedure on the same day.

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6
Q

Objective of Chapter 7
*Purpose of NCCI/ CCI
*Recognize modifier w/ NCCI edits
*Medicaid uses NCCI differently than CMS
*Difference between LCD & NCD

A

National Correct Coding Initiative

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7
Q

NCCI aka CCI
National Correct Coding Initiative

A

*Implemented by CMS
*Promotes correct coding methods
*Controls improper assignment of codes that result in inappropriate reimbursement.

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8
Q

NCCI aka CCI
National Correct Coding Initiative
composed of two

A

provider-type choices of code pair edits.

  1. Practitioner
  2. Hospital
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9
Q

NCCI aka CCI
National Correct Coding Initiative
composed of three

A

provider-type choices of MUEs
(MUE is the number of units on P/S that can be reported on same day)

MUE (number of units)
Medically Unlikely Edits

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10
Q

Code Pair Edits

A

NCCI - Practitioners (including ASC)
NCCI - Hospital (including see card 12)

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11
Q

NCCI Edits
National Correct Coding Initiative
Practitioners

A

Code pair edits applied to claims submitted by physician, non-physician practitioner, ASCs Ambulatory Surgery Center

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12
Q

NCCI Edits
National Correct Coding Initiative
Hospital

A

Code pair edits applied to TOBs (Types of Bills) subject to OCE (Outpatient Code Editor) Hospitals, SNF, Home Health, Outpatient Physical Therapy, Speech-Language Pathology, Comprehensive OP Rehab Facilities.

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13
Q

NCCI Modifiers

A

Anatomic Modifiers
E1-E4
FA
F1-F9
TA
T1-T9
LT
RT
LC
LD
RC
LM
RI

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14
Q

Global surgery modifiers

A

24,25,57,58,78,79

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15
Q

Other modifiers

A

27,59,91, XE, XS, XP, XU

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16
Q

Modifiers 76

Modifiers 77

Are NOT NCCI associated modifiers and cannot…

A

Repeat procedure/service by same provider.

Repeat procedure by another provider

be used to bypass edits.

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17
Q

Modifier 25

A

Significant, separately id’ E/M service by same provider on the same day of procedure / service.

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18
Q

Modifier 25
Example

A

A pt. sees Dr. for HBP, high Lipids, depression… he also has a skin lesion

Provider performs hx exam w/ MDM (Medical Decision Making) of moderate complexity 99214 … for above reason.

In addition, provider looks at lesion. It’s benign neoplasm and removes it w/ excised diameter of 1.8cm (11402)

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19
Q

Basically, the National Correct Coding Initiative NCCI is a Form that looks like a Superbill with columns.

CCI short for NCCI

S/P: service or product.

A

99214-25 I10, E78.5, F32.A, etc
11402

would like this…

Column 1 Column 2 Etc Etc
11402 99214

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20
Q

Staged or related procedure/service by the same provider or other during post-op.

A

Example:

a pt is brought in for laparoscopic appendectomy. after procedure initiated, it’s converted to open appendectomy.

Code is 44950 Appendectomy only.

Code 44970 Laparoscopy, according to the NCCI edits would NOT be reported in addition.

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21
Q

Modifier 59
According to the NCCI (National Correct Coding Initiative)

A

Provider performs colonoscopy.

Removes one lesion from one place 44384-59 on Column 2

another lesion from different place. 45385 on Column 1

(45385) is considered inclusive in 44384

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22
Q

Modifier XU
NCCI
National Correct Coding Initiative

A

*This modifier is for non-overlapping services.

Example:
Provider performs a debridement of subcutaneous tissue front leg.. 5sqcm
(11042)

Second debridement on the left calf 7cm (11042)

In the Column1/Column 2 Edits Chart
it would be

Column 1 Column 2
11043 11042

*I don’t know where the heck 11043 came from, but that’s what it says.

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23
Q

Methodologies
1. PTP edits for

A

procedure-to-procedure edits for providers and ASC

(Ambulatory Surgical Center)

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24
Q

Methodologies
2. PTP edits

PTP: Procedure-to-Procedure

A

For
Outpatient Hospital Services

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25
Q

Methodologies
3. PTP edits

PTP: Procedure-to-Procedure

A

for DME
Durable Medical Equipment

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26
Q

Methodologies
4. PTP edits

PTP: Procedure-to-Procedure

A

For MUEs
(Medically Unlikely Edits) for
Practitioners and ASC
Ambulatory Surgical Centers

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27
Q

Methodology w/ MUEs for

(Medically Unlikely Edits)

A

Outpatient Hospital Services for Hospitals

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28
Q

Methodology w/ MUE for

(Medically Unlikely Edits: number of units that can be reported on the same day)

A

DME
durable medical equipment,

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29
Q

Each component for each methodology has the following.
1
2
3
4

A

A set of edits

Definitions of types of claims subject to edits.

Claim adjudication rules.

Rules for appeals of denied payment.

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30
Q

MUE table format on CMS website.

Medically Unlikely Edits
(Max. number of units that can be reported on the same day)

A

First column on table is:
HCPCS/CPT Code

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31
Q

Second Column of the MUE table format.

MUE: max. number of units reported same day.

A

Second column on table is:
Practitioner Services MUE values
(indicates number of units that may be billed for the HCPCS L11 or CPT.)

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32
Q

Third Column of the MUE table format.

MUE: max. number of units reported same day.

A

Third Column is MAI (Adjudication Indicator). This indicates the type of MUE and basis.

MAI: Adjudication Indicator.
MAI 2: indicates an edit based on regulation (policy) including code descriptor or its anatomy.

MAI 3: indicates an edit for which the MUE is based on clinical information, such as billing patterns, prescribing instruction, or other information.

MAI 3: is the most common per day edit.

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33
Q

Fourth Column of the MUE table format.

MUE: max. number of units reported same day.

A

Column 4:
MUE (number of units reported same day) Rationale. This specified the adjudication indicator as to whether it is due to anatomic consideration, nature of service, CPT, clinical data, or CMS policy.

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34
Q

Example:
CPT 40842 Unilateral
CPT 40843 Bilateral

(I’m still watching the video portion of the chapter)

A

The codes can only be reported once.

Bcuz 40842 indicates it is unilateral, if performed twice, the procedure becomes bilateral which is 40843.

First Column of table: codes 40842, 40843

Second Column on table: 1 and 1 (representing the above code one each)

Third Column: MUE Adjudication.
2 Date of Service
Edit: Policy (for each code)

Fourth Column: MUE Rationale
CPT Code Descriptor/CPT (on both codes columns)

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35
Q

NCDs
National Coverage Determination

A

Make policy when MAC will pay s/p

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36
Q

MAC:
Medicare Administrative Contractor
in CA it’s Noridian.

A

Interpret guidelines into regional policies. LCD only have jurisdiction within their regional area.

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37
Q

NCDs
National Coverage Determination

vs

LCD
Local Coverage Determination

A

NCD: there are no procedure or diagnosis codes. Info related to procedure and coverage or non-coverage of the procedure.

LCD: Goes into further detail, providing additional requirements that MUST be met for coverage.

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38
Q

NCD has generalized information about p/s

NCD: National Coverage Determination

A

Looks like a letter w/ the following heading.

Description Information
Benefit Category
Diagnostic Services
Diagnostic Test

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39
Q

The LCD starts by giving the

LCD: Local Coverage Determination

A

Jurisdiction

Effective dates for the policy

Where the regulatory can be found for policy.

On the LCD website you click on the button “Coverage Guidance” to find detailed information.

Gives you a list of documentation that must be included in the medical record.
It could be results of labs, xray, images etc. etc. depending on p/s

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40
Q

All previous notes are from the video on Chapter 7

A

I will now take notes on the script.

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41
Q

NCCI: National Correct Coding Initiative
shortened to CCI

A

is an automated edit system used to indicate CPT code pairs and whether they can be reported on the same DOS, on same beneficiary, same provider.

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42
Q

NCCI: National Correct Coding Initiative

aka: CCI

A

Policies are based on.
*analysis of standard medical & surgical practice.

*coding conventions included in CPT

*Coding guidelines

*local and national coverage determination

*a review of current ceding practices.

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43
Q

The edits are updated …

A

Quarterly by CMS

and policy manual yearly.

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44
Q

NCCI: National Correct Coding Initiative

aka: CCI

p/s: procedures and services.

A

Used by Billers, Coders to determine codes considered by CMS to be bundled for p/s

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45
Q

Bundled p/s are NOT

A

reported separately.

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46
Q

The components of a bundled p/s are included in the

A

comprehensive procedure code.

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47
Q

Billing Tip
Beware.

A

Reporting bundled procedure codes in addition to the major procedure code is characterized as unbundling and, if repeated with enough frequency, could be considered an act of fraud.

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48
Q

Local CMS carrier
MACs such as Noridian

MAC: Medicare Administrative Contractor

A

Began using NCCI aka CCI since 1996.

Incorporated by ACA
Affordable Care Act.

Many commercial plans also utilize the NCCI edits in their claims processing.

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49
Q

NCCI aka CCI

A

Used by Billers, Coders to determine codes considered by CMS to be bundled for p/s

50
Q

Each MAC

A

and the jurisdiction they are responsible for may have differing policies.

51
Q

NCCI aka CCI
National Correct Code Initiative
(bundled codes)

A

NCCI were added to OCE (Outpatient Code Editor) to assist MAC process Part B.

52
Q

NCCI aka CCI
(bundled codes)

A

includes two types of edits.

  1. PTP procedure-to-procedure
    *code pairs should NOT be billed together bcuz one p/s inherently includes the other.

MEE: Mutually Exclusive Edits
are included in the PTP edits. These codes unlikely to be performed on the same patient on the same DOS.

Example: Two different types of lab test that would produce the same result as one test. Such as C/S maybe?

53
Q

NCCI aka CCI
(bundled codes)

A

Number two … types of edits.

  1. MUE: Medically Unlikely Edits
    Indicate a max number of UOS: Units Of Service allowable for a single CPT or HCPCS on a single DOS for a beneficiary.
54
Q

NCCI aka CCI
(bundled codes)
is composed of two provider type choices of codes …

A

and three MUEs choices.

MUE: Medically Unlikely Edits
(Maximum allowed UOS)

UOS: Units Of Service.

55
Q

PTP Code Pair Edits

PTP: procedure-to-procedure

OCE: Outpatient Code Editor
OPPS: OP Prospective Pay System
TOBs: Type Of Bills
OP: Outpatient

A
  1. Provider: NCCI Edits apply to claims by Providers and ASC Ambulaory Surgery Center.
  2. Hospitals: applied to TOBs subject to OCE for OPPS also SNF, Home health, OP Physical Therapy, Speech language, Comprehensive OP Rehab facilities.
56
Q

3 MUEs

Medically Unlikely Edits
(Maximum allowed UOS)

UOS: Units Of Service
TOBs: Types of Bills

A

These 3 are subject to edits.

  1. Provider/Practitioner claims.
  2. DME: durable medical equip suppliers
  3. Outpatient MUEs (Max allowed UOS) Claims TOBs 13X, 14X, Critical Access Hospitals 85X.
57
Q

NCCI aka CCI edits are based on the

A

*Standards of care

*Services integral to another are considered components of the more comprehensive services.

*Comprehensive code on Column 1
*Component code on Column 2

58
Q

Some services that are integral to many procedures include:

A

*Cleaning, shaving prepping skin
*Draping and positioning patient
*Insertion of urinary catheter
*Surgical approach
*Surgical cultures
*Surgical closure

59
Q

NCCI aka CCI
(Bundled codes)

General principals applied to the edits.

A
  1. The component (column 2) is standard care when performing comprehensive (column1) service.
  2. The component is necessary to complete comprehensive service.
  3. Component is NOT separately distinguishable s/p from comprehensive s/p.
60
Q

Examples of s/p NOT separately billed, they are components s/p of more comprehensive.

A

MEDICAL: cardiac arrest (93015-93018) includes multiple EKG (93005-93010) is NOT separately billed.

SURGICAL: Myringotomy (69421) requires access to tympanic; removal of impacted cerumen (69210) is NOT separately billed.

61
Q

This is not a medical abbreviation.

it’s my own way of remembering.

CC: Comprehensive/Component
C1C2: Column 1 & Column 2

A

CC: Comprehensive/Component

Column 1 edits
Column 2 edits

62
Q

PTP Coding Edits: Web

PTP: Procedure-to-Procedure

A

(https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-procedure-procedure-ptp-edits)

63
Q

CCM: Correct Coding Modifier

The CCM format includes an indicator for the CC table.

This indicator determines a CCM to bypass the edit.

PTP: Procedure-to-Procedure.

A

Indicators:

0 = A CCM is not allowed and will bypass the edits.

1= A CCM is allowed and will bypass the edits.

9= NCCI edits does NOT apply to this PTP code pair. The edit was deleted.

64
Q

EXAMPLE:

CCM: Correct Coding Modifier

A

Code 10081 (incision & drainage)
Code 69990 (complicated: technique requires operating microscope)

Because the CCM indicator is 0, no modifier can be used to bypass the edits. In other words, you cannot bill these two codes together.

65
Q

EXAMPLE:

CCM: Correct Coding Modifier

A

Code 10081(Incision & Drainage)
Code 10080 (Complicated) if Modifier 59 is supported by the documentation.
This is supported by CCM indicator 1. The modifier 59 is added to Column 2 code.

66
Q

Biling Tip

A

When a payer denies a procedure or service as inclusive to (or included in) another procedure, first review the bundling edits to see if these two procedures are bundled. If a modifier is allowed, and two unique services were performed, bill the two procedures with the appropriate modifier, and make sure documentation is available to support the billing of both procedures. Many payers utilize the NCCI edits and add their own edits to the NCCI edits. The provider’s contract with the insurance payer may also stipulate bundling edits.

67
Q

Section Review 7.1

On the Modifier Column on the Table there’s a 1.

0= not allowed
1= allowed
9= not applicable

A

Answer: C. 11000 can be reported with 11042 when circumstances qualify for an NCCI modifier

Rationale: The code pair 11042 & 11000 shows a CCM indicator 1 which indicates the two codes may be reported together when circumstances qualify for an NCCI modifier. For example, if the two procedures are performed on different locations, a modifier can be used to indicate the separate procedures.

68
Q

Medical Necessity

A

Answer: D. Medical necessity is a determination made by the payer to decide if a service is necessary for treatment, prevention of Illness, or to diagnose a patient.

Rationale: The payer determines medical necessity. Support of medical necessity is made with diagnosis codes and clinical documentation.

69
Q

Who were the NCCI edits originally developed to be used by?

A

MACs: Medicare Administrative Contractors

70
Q

The NCCI edits have Column 1 and Column 2 codes and provide an indicator to determine whether a modifier can be used. Which indicator is used to tell the biller a modifier is never allowed?

A

Answer: A. 0

Rationale: Zero indicates that the component code may not be separately billed. 9 is used when a modifier is not specified, 1 allows the use of a modifier. A is not an indicator used for NCCI.

71
Q

What are services that are a standard of medical/surgical practice?

A

Answer: A. Integral and included in the procedure

Rationale: The cleaning, prepping of the area, draping and positioning the patient, inserting a catheter, cultures, and opening and closing of the surgical site are all considered to be the standard of care and are not separately billable.

72
Q

Modifiers and NCCI Edits

NCCI aka CCI
(bundled codes)

A

HCPCS or CPTs may be used to bypass NCCI edits when appropriate.

73
Q

It is important as a biller to understand modifier usage. This allows for proper appeals to be filed when warranted and to understand when a write-off should be done instead.

A

The modifiers that may be used to bypass the NCCI edits include:

Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI

Global surgery modifiers: 24, 25, 57, 58, 78, 79

Other modifiers: 27, 59, 91, XE, XS, XP, XU

74
Q

Modifiers 76 & 77
Repeat p/s etc.

A

Are not NCCI (aka CCI) (bundled codes)
edit modifiers and cannot be used to bypass edits.

75
Q

E1-E4 describe

A

upper and lower, right and left eyelids (different anatomic sites)

76
Q

FA, F1-F9 describe

A

left and right hands, and specific fingers of each (different anatomic sites)

77
Q

TA, T1-T9 describe

A

left and right foot with each specific toe of each (different anatomic sites)

78
Q

Example:

A patient has a complete, permanent removal of a deformed toenail on bilateral great toes. Code 11750 was billed twice, one for each toe and the claim was denied as a duplicate.

A

By adding modifier TA (left great toe) and T5 (right great toe) to indicate different anatomic sites (duplication of code), the claim should be paid.

79
Q

The NCCI Policy Manual discusses NCCI modifiers 25, 58, and 59 specifically.

A

Modifier 25 is appended to an E/M p/s when reported w/ 000 or 010 global days, p/s not covered XXX global indicator.

A separate E/M should NOT be billed.

80
Q

Page 82
Example: Modifier 25

Pt. sees provider f/u HBP, lipid, depression. Also, skin lesion that’s removed.

A

CCM: Correct Coding Modifier

The CCM 1 (see below) indicates the two codes can be reported.

Modifier
0 = not allowed
1= allowed
9= not applicable

Codes assigned are
11402 (skin lesion removed)
99214-25 (Office visit)

Modifier 25 may only be appended to E/M codes, not procedure codes.

81
Q

In the above situation, the dx code and p/s used for the E/M will be different.

This will support medical necessity.

A

The use of different dx is not required for Mod 25 but applies in this situation.

82
Q

Billing Tip

The NCCI edits state, “In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service.”

A

This statement supports the necessity for the evaluation and management service to be separate from the surgical procedure to be reported separately.

83
Q

Modifier 58

Staged or related p/s, same physician, during post-op.

A

NCCI (aka CCI)
(bundled codes) w/ endoscopic procedures.

A diagnostic procedure resulting in a decision to perform an open procedure is separately reportable.

Unless… see next slide

84
Q

Unless it’s a “scout”

A

endoscopy to assess anatomic landmarks and/or extent of disease.

85
Q

The NCCI does not contain all edits regarding bundling of laparoscopic procedures into open procedures because …

A

the number of possible code combinations is too great.

86
Q

The policy manual states that the basic principle that any planned endoscopic procedure that fails and is converted to an open procedure …

A

is not separately reportable. It does not matter whether there is an NCCI edit.

87
Q

Diagnostic endoscopies are also not separately reportable with another endoscopic procedure of the same organ(s)

A

when performed at the same encounter, or with a surgical endoscopic procedure of the same body cavity when performed at the same encounter.

88
Q

Example:
A laparoscopic appendectomy 44950

A

converted to open appendectomy. 44970

Column 1 Column 2
44950 44970

89
Q

According to NCCI (aka CCI)
(bundled codes)

A

code 4970 is included in code 44950.

The CCM (correct coding modifier) column there’s a (0)

90
Q

Modifier 59 Distinct procedural service.

A

CCI reiterates the CPT codes.

Under certain circumstances, it may be necessary to indicate that a p/s was distinct or independent from other non-E/M from same day.

91
Q

Modifier 59 is used to identify p/s, other than E/M

A

that are not normally reported together but are appropriate under the circumstances.

92
Q

Modifier 59

Is used when it’s necessary to indicate that a p/s was distinct or independent from other non E/M service on same day.

A

*Documentation supports different session.

*Different procedure or surgery

*Different site/organ

*Different incision/excision

*Different lesion, injury not ordinarily encountered or performed on the same day by same individual.

93
Q

CMS defined four new HCPCS modifiers that are subsets of Mod 59.

They are specific/descriptive.

A

XE - separate encounter

XS - Separate structure

XP - Separate provider

XU - Unusual non overlapping service

94
Q

X [ESPU]
It’s more specific than Modifier 59

A

Jan 1, 2015 CMS began accepting it along w/ Modifier. 59

NOT used together on same claim.

95
Q

The code would look like this

A

11303 Biopsy etc. etc.
11102 is a component.

The provider reports.
11303
11102-XU

96
Q

Medicaid and NCCI
NCCI (aka CCI)
(Bundled codes)

A

ACA required Medicaid to utilize NCCI edits.

CMS allows to deactivate edits that conflict w/ state laws.

97
Q

The Medicaid NCCI program consists of six methodologies:

A

1.A methodology with Procedure-to-Procedure (PTP) edits for practitioner and ambulatory surgical center (ASC) services

2.A methodology with PTP edits outpatient hospital services

3.A methodology with PTP edits for durable medical equipment

4.A methodology with MUEs for practitioner and ASC services

5.A methodology with MUEs for outpatient hospital services for hospitals

6.A methodology with MUEs for durable medical equipment

98
Q

Page 83
Each of the Medicaid NCCI methodologies has four components.

A
  1. a set of edits
  2. definitions of types of claims
  3. adjudication rules
  4. set of rules for appeals of denied payments.
99
Q

MUEs
Medically Unlikely Edits

To help reduce the paid claims error rate for McrB MUEs were developed.

A

Maximum units of service
UOS

*for a single day of service
*for a specific HCPCS/CPT code

100
Q

Billing Tip

A

If a code is denied for MUE
Medically Unlikely Edits (max UOS) the ABN won’t be applicable, patient can’t be billed.

101
Q

Tables don’t copy as a Table on this study deck, but on page 83 there is a Table.

A

First line
HCPCS/CPT code: 52648

Second line
Practitioner Services MUE Values: 1

Third line
MUE Adjudication Indicator:
2 Date of Service Edit: Policy or
3 Date of Service Edit: Clinical
etc. etc.

Fourth line
MUE Rationale:
Anatomic Consideration or
Nature of S/P

102
Q

HCPCS/CPT® Code

This is first line on table above.

A

This indicates the HCPCS Level II code or CPT® code.

103
Q

Practitioner Services MUE Values

this is from second line on table above.

A

This indicates the number of units that may be billed for the HCPCS Level II code or CPT® code.

104
Q

MUE Adjudication Indicator (MAI)

This is the Third Line of the Table above.

A

*The type of MUE and its basis

*MAI of 2 is based on policy

*MAI of 3 based on clinical information

105
Q

MUE Rationale

Fourth line from Table above.

A

indicator as to whether it’s due to anatomic consideration, nature of s/p

106
Q

MUE Table found on the CMS website.

A

https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-medically-unlikely-edits

107
Q

National Coverage Determinations (NCD)

Local Coverage Determinations (LCD)

National Coverage Analyses (NCAs)

A

NCAs include proposed NCD decisions.

To be used by Medicare Contractors, provider and HC professionals.

108
Q

NCDs polices based on SSA social security act and Medicare regulations.

A

to indicated if s/p can be paid for by Medicare. Denial decisions are based on the policy unless otherwise specifically noted.

109
Q

MACs
Medicare Admin Contractors are to follow NCD policies.

A

If s/p not mentioned in NCD then MAC can make an LCD.

110
Q

An LCD is mandated at the…

A

MAC level.

111
Q

MACs also define what codes are needed for coverage.

A

When there’s an NCD and LCD for the same s/p, the NCD takes precedence.

112
Q

On page 84 it talks about the
National Coverage Determination for MRI (220.2)

MRA: Magnetic Resonance Angiography

Medicare will cover MRA or CA to evaluate peripheral arteries; however both may be needed.

A

it explains on and on
*Method of operation
*General Clinical Utility
*Indications and Limitations of coverage
*Nationally covered MRI and MRA indications

113
Q

Page 88 Review 7.2

The provider performs a transforaminal epidural with fluoroscopy (imaging guidance) into the left side of the thoracic spine (64479). He also performs an aspiration/injection into the left trochanteric bursa (20610). Based on this portion of the NCCI table and the scenario below, which modifier is appropriate to report?

A

Answer: B. XS

Rationale: Based on the 2015 Revision of Modifier 59 the subset of codes X [ESPU] modifier guidelines XS would be appropriate to indicate a distinct separate structure or organ was involved. Modifier 59 would not be used as XS is more specific. CMS states that both modifiers would not be reported on the same date of service.

There was also a Table provided for this question.

Column 1: 64479

Column 2: 20610

Effective Date: 20010701

Deletion Date *=no data: *

PTP Edit Rationale: misuse of column two code w/ column one code.

114
Q

What is an MUE?

*max number of times s/p

*one beneficiary

*on DOS

A

Answer: D. Edits showing the maximum number of times a procedure can be performed for one beneficiary in one date of service.

Rationale: MUEs define the maximum units of service that a provider would report, under most circumstances, for a single beneficiary, on a single date of service, for a specific HCPCS/CPT® code.

115
Q

A patient has a breast biopsy with placement of localization device (19083) with subsequent mastectomy (19301) at the same session after the biopsy is proven to be malignant. What modifier would be used for this scenario?

A

Answer: B. 58

Rationale: Modifier 58 is correct. A staged or related procedure by the same physician that is performed at the same encounter is bundled; however, a modifier is allowed. Referring to Appendix A in the CPT® code book modifier 58 can be reported for three different reasons. For this question modifier 58 is reported to indicate the subsequent mastectomy was more extensive than the original procedure.

116
Q

Coverage determination L35175 for magnetic resonance imaging includes coverage guidelines (referenced above in reading material). Which of the following is supported in these guidelines?

A

Answer: B. Patients with pacemakers or intracranial metallic objects are NOT suitable candidates for MRI.

Rationale: The medical policy states, “CT scans (as opposed to MRI evaluations) are used effectively in the following situations or conditions:

  1. Patients who are not suitable candidates for MRI evaluation: a. Because of a pacemaker or intracranial metallic objects b. Because of extreme obesity c. Because of an inability to lie still
  2. Patients whose condition requires the visualization of fine bone detail or calcification
  3. Patients with the following conditions a. Acute CNS Hemorrhage b. Strokes or encephalomalacia c. New onset seizures, particularly if a focal component is present (contrast agent is appropriate for these patients) d. Intracranial (sic) lesions large enough to cause increased intracranial pressure (CT scan is useful to determine gross margins between tumor and edematous brain).”
117
Q

NCCI policy specifically discusses what 3 modifiers?

A

Answer: B. 25, 58, 59

Rationale: Because of the complexity of the modifiers, NCCI specifically discusses varying scenarios for modifiers 25 (separately identifiable procedure), 58 (staged or related procedure), and 59 (distinct procedural service) and how they apply to NCCI edits.

118
Q

MUE
Medically Unlikely Edits

A

Part of NCCI aka CCI …

*Places limits on the frequency on codes billed on same DOS by same Provider for a single beneficiary.

119
Q

NCCI/CCI

National Correct Coding Initiative

A

A CMS program to prevent improper payment of s/p that should not be submitted together.

120
Q

OCE
Outpatient Code Editor

A

Software that edits OP Hospital claims to detect incorrect billing to determine if the ASC Ambulatory Surgery Center limit should apply to each claim and reviews each HCPCS and ICD-10-CM code for validity and coverage.

cpb certified professional biller (15 decks)

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