Navigating Through Coding Miriam Ivanova Rodriguez MD MSM

Objectives �Recognize the information each of the tools can provide �Distinguish which resource is

Coding Tools � Internet Only Manuals (IOM) � National Correct Coding Initiative (NCCI) �

Internet Only Manuals (IOM) IOMs are record that provided information of the day-to-day operations,

Available IOMs Publicatio n Title 100 Introduction 100 -01 Medicare General Information, Eligibility and

Available IOMs Publicatio n Title 100 -13 Medicaid State Childrens Health Insurance Program (Under

What IOM to Use �What do you want to know? �Beneficiary Information �Claims Processing

Example What are rules for Critical Care?

National Correct Coding Initiative (NCCI) �Developed by Medicare to promote national correct coding methodologies

Locating National Correct Coding Initiative (NCCI) �How to locate: �www. CMS. gov

Locating National Correct Coding Initiative (NCCI)

Viewing NCCIs � 2 Files will appear (Excel or Text files) OR

NCCI Modifiers Modifie r Description Place on 24 Unrelated E/M service by the same

NCCI Manual Note: The NCCI Policy Manual is updated annually.

Medically Unlikely Edits (MUE) �The Medically Unlikely Edits are an addition to the NCCI

Locating Medically Unlikely Edits (MUE) �If you already have the NCCI “PTP Coding Edits”

Locating Medically Unlikely Edits (MUE) �How to locate: �www. CMS. gov

Viewing MUEs � 2 Files will appear (Excel or Text files) OR

MUE Adjudication Indicators 1 Adjudicated as a claim line 2 Edit units per day

Medicare Physician Fee Schedule (MPFS) �The Medicare Physician Fee Schedule is maintained by CMS.

Locating MPFS Quarters A= 1 B=2 C=3 D=4 R= Revised

NCDs and LCDs �National Coverage Determination �Describes whether specific medical items, services, treatment procedures,

NCDs and LCDs �Frequency �Can develop at any time � 6 -9 month process

NCD �Medicare National Coverage Determinations Manual (100 -03) may be located at: http: //www.

National E/M Benchmarking Scroll Down to “Related Links”

National E/M Benchmarking �Calculating Benchmarks �Add all the “Allowed Services” for the code set

Website Hyperlinks �Internet Only Manuals �National Correct Coding Initiative Manual �National Correct Coding Initiative

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Navigating Through Coding Miriam Ivanova Rodriguez, MD, MSM, CPC Shannon M. Smith, CPC

Objectives �Recognize the information each of the tools can provide �Distinguish which resource is most appropriate to use for different scenarios �Acquire the power to quickly and easily locate each of the coding resources

Coding Tools � Internet Only Manuals (IOM) � National Correct Coding Initiative (NCCI) � Medical Unlikely Edits (MUE) � National Coverage Determination (NCD) � Local Coverage Determination (LCD) � National Benchmarking for E/M Services by Specialty

Internet Only Manuals (IOM) IOMs are record that provided information of the day-to-day operations, instructions, policies and procedures based on statutes, regulations, guidelines and directive of the Centers of Medicare and Medicaid Services (CMS) program. The CMS program components, providers, contractors, Medicare Advantage organizations and state survey agencies use the IOM to administer CMS programs. MEDICARE BIBLE

Locating IOMs

How to Locate

Available IOMs Publicatio n Title 100 Introduction 100 -01 Medicare General Information, Eligibility and Entitlement Manual 100 -02 Medicare Benefit Policy Manual 100 -03 Medicare National Coverage Determinations (NCD) Manual 100 -04 Medicare Claims Processing Manual 100 -05 Medicare Secondary Payer Manual 100 -06 Medicare Financial Management Manual 100 -07 State Operations Manual 100 -08 Medicare Program Integrity Manual 100 -09 Medicare Contractor Beneficiary and Provider Communications Manual 100 -10 Quality Improvement Organization Manual

Available IOMs Publicatio n Title 100 -13 Medicaid State Childrens Health Insurance Program (Under Development) 100 -14 Medicare ESRD Network Organizations Manual 100 -15 Medicaid Integrity Program (MIP) 100 -16 Medicare Managed Care Manual 100 -17 CMS/Business Partners Systems Security Manual 100 -18 Medicare Prescription Drug Benefit Manual 100 -19 Demonstrations 100 -20 One-Time Notification 100 -21 Reserved 100 -22 Medicare Quality Reporting Incentive Programs Manual 100 -23 Payment Error Rate Measurement (Under Development) 100 -24 State Buy-In Manual

What IOM to Use �What do you want to know? �Beneficiary Information �Claims Processing �Managed Care (Alternative Medicare Program) �Is there a specific facility type? �Part A vs. Part B �SNF �ESRD

Example What are rules for Critical Care?

Example

National Correct Coding Initiative (NCCI) �Developed by Medicare to promote national correct coding methodologies and to control improper coding leading to improper payments. Also known as CCI edits. �Updated quarterly �The NCCI will provide Procedure-to-Procedure (PTP) code pair edits when billed together; otherwise know as “bundled services”. �Advance Beneficiary Notice (ABN) cannot be used for payment recoupment for NCCI edits.

Locating National Correct Coding Initiative (NCCI) �How to locate: �www. CMS. gov

Locating National Correct Coding Initiative (NCCI)

NCCI Hint

Viewing NCCIs

Viewing NCCIs � 2 Files will appear (Excel or Text files) OR

Viewing NCCIs

Reading NCCI

Modifier Indicators

NCCI Modifiers Modifie r Description Place on 24 Unrelated E/M service by the same physician during a postoperative period E/M Only 25 Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service E/M Only 57 Decision for surgery Procedure Only 58 Staged or related procedure or service by the same physician during the postoperative period Procedure Only 59 Distinct Procedural Service Procedure Only 78 Unplanned return to the operation/procedure room by the same physician following initial procedure for a related procedure during the postop period Procedure Only 79 Unrelated procedure or service by the same physician during the postop period Procedure Only 91 Repeat clinical diagnostic laboratory test Diagnostic Test XE Separate encounter: distinct service occurring at a separate encounter Procedure Only Note: This is not an all inclusive list of NCCI modifiers. XP Separate Practitioner: distinct service performed by a different Procedure

Reading NCCI Modifier 59

Reading NCCI Modifier 25

NCCI Disclaimer

NCCI Manual

NCCI Manual Note: The NCCI Policy Manual is updated annually.

NCCI Manual

Medically Unlikely Edits (MUE) �The Medically Unlikely Edits are an addition to the NCCI maintained by Medicare. �An MUE is a maximum number of Units of Service (UOS) allowable under most circumstances for a single CPT/HCPCS code billed by a provider on a date of service for a single beneficiary.

Locating Medically Unlikely Edits (MUE) �If you already have the NCCI “PTP Coding Edits” or Manual screen up you may go straight to the MUEs

Locating Medically Unlikely Edits (MUE) �How to locate: �www. CMS. gov

Locating Medically Unlikely Edits (MUE)

Viewing MUEs

Viewing MUEs � 2 Files will appear (Excel or Text files) OR

Reading MUEs

MUE Adjudication Indicators 1 Adjudicated as a claim line 2 Edit units per day 3 Per day edits based on clinical benchmarks (may appeal) https: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNMatters. Articles/downloads/MM 8853. pdf

Reading MUEs

Medicare Physician Fee Schedule (MPFS) �The Medicare Physician Fee Schedule is maintained by CMS. This file provides includes: �Global periods �Associated RVUs �Service status indicators (A, B, T, etc. ) �Payment policy indicators (assistance, bilateral, multiple procedures, etc. ) �Geographic practice cost index �Conversion factors **This information is provided for more than 10, 000 physician services**

Locating MPFS

Locating MPFS Quarters A= 1 B=2 C=3 D=4 R= Revised

Locating MPFS

Reading MPFS

MPFS Manual

Reading MPFS

Locating MPFS

Reading MPFS

Modifier Lookup

NCDs and LCDs �National Coverage Determination �Describes whether specific medical items, services, treatment procedures, or technologies can be paid under Medicare �Policy regulated by CMS �Local Coverage Determination �A determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis �Policy regulated by each MAC or FI

NCDs and LCDs �Frequency �Can develop at any time � 6 -9 month process �Labs updated quarterly (NCD) �Medical Necessity �Treatment �Diagnosis �Indications and Limitations �Criteria **LCDs will take precedence over NCDs**

NCD �Medicare National Coverage Determinations Manual (100 -03) may be located at: http: //www. cms. gov/Regulations-and. Guidance/Manuals/Internet-Only. Manuals-IOMs-Items/CMS 014961. html

Locating NCDs

Reading NCDs

NCDs…Don’t Be Fooled

LCD

PGBA Website

LCD

LCD

LCD

LCD

LCD

LCD

LCD

LCD

LCD

LCD

LCD

National E/M Benchmarking

National E/M Benchmarking Scroll Down to “Related Links”

National E/M Benchmarking

National E/M Benchmarking �Calculating Benchmarks �Add all the “Allowed Services” for the code set you are needing � 99201 -99205 or 99211 -99215 (New vs. Est Outpatient Services) �Divide the of the “Allowed Services” for specific E/M code by the sum or “Total Allowed Services” of the code set Example: 99201 - 11800/1674855= 0. 70%

National E/M Benchmarking

Website Hyperlinks �Internet Only Manuals �National Correct Coding Initiative Manual �National Correct Coding Initiative Edits �Medically Unlikely Edits �National Coverage Determinations �SC Local Coverage Determinations Part A �SC Local Coverage Determinations Part B �National Benchmarking

QUESTIONS