From the Chair of the Commission on Economics
Gregory N. Nicola, MD, FACR
Depending on your practice, you may or may not be involved in coding, and no, I don’t mean computer programming or AI. I am talking about coding for insurance claims. When an insurance claim is submitted, there is at least one Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) code associated with the claim. It is important that the codes associated with an insurance claim are appropriate to ensure proper payment and avoidance of fraud.
(For an in-depth discussion about creating CPT codes and their impact, please refer to the Bulletin articles “There should be a CPT code for that!” Part 1 and Part 2 by Mark Alson, MD, FACR, RCC, prior ACR Advisor to the AMA CPT Editorial Panel.)
So, back to the subject, what is the National Correct Coding Initiative? The National Correct Coding Initiative (NCCI) is a program developed by CMS to ensure that uniform payment policies and procedures are followed and to prevent improper coding that leads to inappropriate payment.
The NCCI accomplishes its goals by enforcing three types of edits: Procedure-to-Procedure (PTP) edits, Medically Unlikely Edits (MUEs) and Add-on Code (AOC) edits. The specific edits can be found on the CMS website as linked in the sentence before. Now, let’s go through each edit and provide examples.
PTP edits prevent inappropriate payment when certain code combinations are reported together. Each row contains one HCPCS or CPT code in “Column One” and a second code in “Column Two.” If a provider reports the two codes of an edit pair for the same patient on the same day, the Column One code is eligible for payment, but the Column Two code is denied, unless, under appropriate circumstances, a NCCI PTP-associated modifier is allowed (noted in the “Modifier” column) to bypass the edit. For example, one row contains CPT code 70450 (CT head or brain without contrast) in Column 1 and code 70480 (CT orbit, sella or posterior fossa, or outer, middle or inner ear) in Column 2. If both codes were performed for the same patient on the same day, only 70450 would be paid and 70480 would be denied. Since this has a “Modifier” of 1, it is possible to override this edit and be reimbursed for both studies with an appropriate modifier. For code pairs with “Modifier” of 0, PTP-associated modifiers cannot be used to bypass the edit.
MUEs set the maximum number of units of service (UOS) for a patient on the same day. NCCI sets MUEs by looking at appropriate reported claims and determining the maximum number of UOS reported for a HCPCS/CPT code by the same provider for the same patient on the same day. For example, CPT code 73560 (XR of the knee joint, one or two views) has an MUE value of 4, while 73565 (XR of both knees) has an MUE value of 1.
AOC edits list HCPCS and CPT add-on codes along with their corresponding primary codes. An add-on code typically describes a service that is almost always performed in conjunction with a separate primary service by the same provider. For example, CPT code 74713 is an add-on code describing a fetal MRI for an additional gestation and should be reported with the primary CPT code 74712 for fetal MRI for a single or first gestation.
Additional issues for Radiological Services CPT codes can be found in the NCCI Policy Manual. For example, CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy defines the UOS for these codes as the patient encounter – not the number of needle placements. So, if multiple biopsies or injections are performed at a single patient encounter, the relevant radiologic guidance code can only be billed once.
In next month’s column, Dr. Mark Alson will delve deeper into what the ACR does with the NCCI program to make sure the edits that CMS proposes and enforces make sense for the practice of radiology.