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Claims coding edits target improper payments, errors

From the September ACP Internist, copyright © 2010 by the American College of Physicians

By Debra Lansey

Every practice wants to code its insurance claims correctly so that they are paid without delay. CPT coding alone can be tricky, even when office staff have years of experience with it. But, in addition to the CPT coding rules, staff need to be fully aware of the claims editing programs that Medicare uses.

CMS uses claims coding edits to prevent overpayment or inappropriate reimbursement of Part B fee schedule services. For the physician fee schedule, there are two basic types of code edits: the Correct Coding Initiative (CCI) and the Medically Unlikely Edits (MUEs). Each edit type is designed to perform a different function.

Claims coding edits target improper payments, errors

CMS owns and determines the final content of CCI and MUE, but it uses a contractor to maintain, refine and develop the coding edits.

Q: What are the CCI edits, and what do they do?

A: The purpose of the CCI edits is to prevent improper payment when incorrect code combinations are reported. Many of the CCI edits are based on the standards of medical/surgical practice. The CCI contains two tables of edits. Using CMS terminology, these are referred to as the Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table. These tables include code pairs that should not be reported together for a number of reasons. An update of the CCI edits is published every quarter.

Services that are integral to another service are component parts of the more comprehensive service. When integral component services have their own Health Care Procedure Coding System or Current Procedural Terminology (HCPCS/CPT) codes, CCI edits place the comprehensive service in Column One and the component service in Column Two. By convention, the Column One service is payable; the Column Two service is not.

Mutually exclusive code edits include those codes that cannot reasonably be performed in the same session. CPT codes that are mutually exclusive, based either on the CPT definition or on the medical impossibility/improbability that the procedures could be performed at the same session, can be identified as code pairs to be bundled in an edit. An example of a mutually exclusive situation is the reporting of an “initial” service and a “subsequent” service. It is contradictory for a service to be classified as both an initial and a subsequent service at the same time.

Q: What are the MUEs, and how do they differ from CCI?

A: CMS developed MUEs to reduce its contractors’ error rate on paid Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a clinician would report under most circumstances for a single beneficiary on a single date of service. Unlike the CCI edits, an MUE edit involves only one code, not a combination of two codes. An MUE based on anatomic considerations is determined by limitations related to anatomic structures. For example, the MUE for cataract surgery would be two since there are only two eyes.

Q: What is ACP policy on the use of coding edits?

A: The College is committed to taking steps to ensure that insurance payers do not bundle services inappropriately by including individually coded services under other separately coded services. This practice is considered acceptable only if the actual description of the relevant codes clearly states that the bundled service or services are part and parcel of the service code for which payment is allowed.

Q: What is the target of the edits?

A: The edit programs target all service types that are paid under Medicare Part B. With so many CPT and HCPCS codes in use, many combinations of codes are possible (it’s over 30 million). There are, in fact, more than 650,000 existing edits. However, because most of the CCI edits relate to surgical services, internists’ claims are not impacted as frequently.

Q: Does the contractor seek input from physicians?

A: In updating and revising its list of edits, the contractor lays out a proposal that may include new, revised or deleted edits. Before the proposed edits are implemented, the national medical specialty societies are given the opportunity to review and comment on the proposals, facilitated by the American Medical Association.

Q: Does ACP intervene in any of the proposed edits?

A: Yes, ACP advocacy functions routinely include reviews of the proposals relevant to internal medicine. We provide recommendations to the contractor. There are numerous instances when ACP has recommended against the implementation of, or for the modification of, a particular edit, and the contractor (and ultimately CMS) followed ACP advice.

For example, CMS followed ACP’s recommendation to allow the billing of an infusion pump (code E0781) with infusion and chemotherapy administration services in appropriate circumstances.

As another example, CMS accepted the recommendation from ACP that the edits bundling pulmonary rehabilitation code G0424 with several cardiac rehabilitation codes (93797, 93798, G0422, and G0423) allow use of CCI modifiers. So, when a physician performs separate sessions of cardiac rehab and pulmonary rehab on the same date of service, both codes may be reported with a CCI-associated modifier.

Q: Which modifiers can be used with the edits?

A: Many edits are constructed in a way that they can be overridden by appropriate use of a modifier. Modifiers 25 (significant, separately identifiable evaluation and management service by the same physician on the same date of service), 59 (distinct procedural service) and 91 (repeat clinical diagnostic laboratory test), as well as most of the anatomical modifiers, can be used with the edits. The downloadable tables show which of the edits can be used with modifiers. The tables are available at the CMS Web site.

Q: Can the edits be appealed?

A: Individual claim payment decisions can be appealed through the Medicare Administrative Contractor (MAC). To inquire about having an MUE or CCI edit reconsidered and then removed from the overall list, physicians can contact the contractor, Correct Coding Solutions, LLC. The address is:

National Correct Coding Initiative
Correct Coding Solutions LLC
P.O. Box 907
Carmel, IN 46082-0907
Attention: Niles R. Rosen, M.D., Medical Director or Linda S. Dietz, RHIA, Coding Specialist

However, physicians can also contact ACP, which already reviewed the edits when they were proposed. The College will almost certainly be able to explain the rationale for standing edits. In addition, ACP is willing to take action to secure a change if we determine that the College failed to challenge an inappropriate edit earlier in the review process.

Q: Are the edits lists something that physicians can access?

A: Yes, and fairly readily, although this wasn’t always the case. Several years ago, ACP urged CMS to make the edits easier to access. The specific issue then was that physicians had inadequate access to the Medicare CCI process, and had difficulty monitoring the CCI because the updates were frequent and costly to obtain. Further, a number of CCI edits were retracted after implementation, causing confusion and placing the burden on physicians to resubmit inappropriately denied claims. Although still a bit unwieldy to navigate due to the sheer size of the files, the CCI edits can now be downloaded free of charge.

The complete edits manual, or sections of the edits manual, can be obtained in one of three ways:1) by purchasing a printed version, or the ASCII text file, from the National Technical Information Service (NTIS) Web site,

2) by contacting NTIS at 800-363-2068 or 703-605-6060, or

3) by downloading the Excel files from the CMS Web site.

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