Chapter 7 Flashcards

Question

Methodologies 3. PTP edits PTP: Procedure-to-Procedure

Answer 1

for DME Durable Medical Equipment

Answer 2

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

Answer 3

Outpatient Hospital Services for Hospitals

Answer 4

DME durable medical equipment,

Answer 5

A set of edits Definitions of types of claims subject to edits. Claim adjudication rules. Rules for appeals of denied payment.

Answer 6

First column on table is: HCPCS/CPT Code

Answer 7

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

Answer 8

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.

Answer 9

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.

Answer 10

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)

Answer 11

Make policy when MAC will pay s/p

Answer 12

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

Answer 13

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.

Answer 14

Looks like a letter w/ the following heading. Description Information Benefit Category Diagnostic Services Diagnostic Test

Answer 15

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

Answer 16

I will now take notes on the script.

Answer 17

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.

Answer 18

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.

Answer 19

Quarterly by CMS and policy manual yearly.

Answer 20

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

Answer 21

reported separately.

Answer 22

comprehensive procedure code.

Answer 23

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.

Answer 24

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.

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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?

Answer 29

Number two ... types of edits. 2. 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.

Answer 30

and three MUEs choices. MUE: Medically Unlikely Edits (Maximum allowed UOS) UOS: Units Of Service.

Answer 31

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.

Answer 32

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.

Answer 33

*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

Answer 34

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

Answer 35

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.

Answer 36

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.

Answer 37

CC: Comprehensive/Component Column 1 edits Column 2 edits

Answer 38

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

Answer 39

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.

Answer 40

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.

Answer 41

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.

Answer 42

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.

Answer 43

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.

Answer 44

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.

Answer 45

MACs: Medicare Administrative Contractors

Answer 46

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.

Answer 47

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.

Answer 48

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

Answer 49

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

Answer 50

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

Answer 51

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

Answer 52

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

Answer 53

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

Answer 54

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.

Answer 55

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.

Answer 56

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.

Answer 57

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

Answer 58

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

Answer 59

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

Answer 60

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

Answer 61

the number of possible code combinations is too great.

Answer 62

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

Answer 63

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

Answer 64

converted to open appendectomy. 44970 Column 1 Column 2 44950 44970

Answer 65

code 4970 is included in code 44950. The CCM (correct coding modifier) column there's a (0)

Answer 66

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.

Answer 67

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

Answer 68

*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.

Answer 69

XE - separate encounter XS - Separate structure XP - Separate provider XU - Unusual non overlapping service

Answer 70

Jan 1, 2015 CMS began accepting it along w/ Modifier. 59 NOT used together on same claim.

Answer 71

11303 Biopsy etc. etc. 11102 is a component. The provider reports. 11303 11102-XU

Answer 72

ACA required Medicaid to utilize NCCI edits. CMS allows to deactivate edits that conflict w/ state laws.

Answer 73

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

Answer 74

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

Answer 75

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

Answer 76

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

Answer 77

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

Answer 78

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

Answer 79

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

Answer 80

*The type of MUE and its basis *MAI of 2 is based on policy *MAI of 3 based on clinical information

Answer 81

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

Answer 82

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

Answer 83

NCAs include proposed NCD decisions. To be used by Medicare Contractors, provider and HC professionals.

Answer 84

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

Answer 85

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

Answer 86

MAC level.

Answer 87

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

Answer 88

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

Answer 89

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.

Answer 90

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.

Answer 91

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.

Answer 92

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).”

Answer 93

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.

Answer 94

Part of NCCI aka CCI ... *Places limits on the frequency on codes billed on same DOS by same Provider for a single beneficiary.

Answer 95

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

Answer 96

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.