Providers - National Coding FAQ's

Q:

What changes to coding will occur?

A:

We are continuously working to enhance our ability to administer payment policies to be more consistent with CMS and AMA. For example, ensuring appropriate use of modifiers, consistency with CMS global surgery guidelines for procedures billed post operatively and supporting appropriate billing for procedures designated as ‘separate procedures’ in the CPT code book.

Q:

What is the effective date of these changes?

A:

March 19, 2007

Q:

Will these changes affect provider reimbursement? If so, which ones?

A:

The fee schedule has not changed. Only the coding policies have been enhanced to more closely align with current national coding and industry standards. These changes may effect the overall reimbursement on a claim.

Q:

What does appropriate modifier usage imply?

A:

Certain modifiers, based on nomenclature or intent of use, may be submitted by a provider to indicate that the services rendered to a patient were performed distinctly and independently of the other services performed on the same day or within a certain period of time.

- Modifier 25 (or 57 [Decision for Surgery] for 90 day procedures) should be used when the Evaluation and Management (E&M) service is distinct and separately identifiable from the CMS designated minor service or procedure (0 or 10 day) being performed the same day (or the day prior to for 90 day procedures).  

- Modifier 24 should be used when the E&M service is unrelated to the CMS designated minor or major service or procedure being performed post operatively.

Q:

What impact will these changes have on after hours and preventative care services?

A:

We are aware that there are some areas where CMS guidelines are inconsistent with our goals for managing our member’s care, therefore, we will continue to encourage you to provide preventative care and after hours services as needed.

Q:

Where can the CMS medical coding policies be obtained?

A:

CMS’s website can be located at: www.CMS.gov. In today’s technology contacting CMS on the web should be sufficient as it is highly used. However, if you feel you need to contact them directly, please feel free to contact one of CMS’s regional representatives at their website or one of the following provider service numbers:

The carrier for Delaware is TrailBlazer Health Enterprises, LLC. The carrier number for Delaware is 00902. This can be accessed through the follow web site: www.cms.hhs.gov/mcd/results.asp?show=all&t=20072985142.
Once you access the site, you select Local Coverage and then you can search by State or Contractor.

National Correct Coding Initiative (NCCI) can be obtained from:
Administer Federal (NTIS)
P.O. Box 50469
Indianapolis, IN 46250-0469

or by calling:
(703)-605-6060 or toll-free (800)-363-2068

Q:

Where can AMA (American Medical Association) coding guidelines be obtained?

A:

The AMA guidelines can be obtained directly from the CPT-4 code manual, visiting their website at www.ama-assn.org, or by contacting them directly at:

American Medical Association
515 N. State Street
Chicago, IL 60610

or by calling:
(800)-621-8225

Q:

Where can the Local Medicare Policies be obtained?

A:

Because there are numerous Medicare Intermediaries that develop local Medicare policies, please refer to the attached list of where to obtain some of these policies or visit www.cms.hhs.gov/mcd/search.asp for a listing of the policies broken down by state.

Q:

Where can the nationally recognized academy & society guidelines be obtained?

A:

Providers may refer to the policies and guidelines that are outlined by each specialty Academy and/or specialty society.

Q:

Below are some specific details with respect to the changes:

A:

Policy: Global Surgery Package
Reference: CMS
Description: According to CMS, all additional medical or surgical services required of the surgeon during the post-operative period because of complications, which do not require additional trips to the operating room are included in the global surgical package. Procedures requiring additional trips to the operating room must be billed with modifiers 58 (staged procedure), 78 (return to OR) or 79 (unrelated procedure or service by physician during post-operative period). Example of specific medical and surgical service for 90 day post-operative period procedure: 20610 (Aspiration of a major joint) is considered included in the global surgical package of code 29880 (Knee arthroscopy with meniscectomy).

Policy: Assistant Surgeons
Reference: CMS
Description: Any procedures in the Medicare list of procedures not allowed or may be allowed for assistant surgeons will be denied with the reason no assist needed for this procedure. For example, the Medicare fee schedule includes a list of procedures where assistant surgeons are not allowed (e.g., CPT 44388 [Colonoscopy], 66150 [Glaucoma surgery], etc.). These are generally procedures that are minor in nature and will be denied if billed with the following modifiers: 80, 81, 82, AS, AM, QB and QU.

Policy: Co-Surgeons
Reference: CMS
Description: Any procedures in the Medicare list of procedures not allowed or may be allowed for co-surgeons will be denied with the reason no co-surgeon needed for this procedure. For example, the Medicare fee schedule includes a list of procedures where co-surgeons are not allowed (e.g., 93510 [Left heart cath], 62280 [Treat spinal cord lesion], etc.). These are generally procedures that are minor in nature and will be denied if billed with modifier 62.

Policy: Separate Procedures
Reference: AMA
Description: The description for many CPT codes includes a parenthetical statement that the procedure represents a "separate procedure." The inclusion of this statement indicates that the procedure should not be reported when it is performed in conjunction with, and related to, a major service. For example, if 30802 (Cauterization and/or ablation, mucosa of turbinates, [separate procedure]) is billed with 31237-31294 (Nasal/ sinus endoscopy, surgical), then 30802 will be denied.

Policy: National Correct Coding Initiative Policies and Guidelines
Reference: CMS
Description: The National Correct Coding Policy Manual is broken into 12 narrative chapters, with each chapter corresponding to a section of the AMA CPT Manual. Each chapter contains correct coding policies as it relates to the procedure codes contained within its section. In many cases, these policies were either never incorporated or were only partially incorporated into the actual NCCI edits. Allergy testing (95004-95078) is not performed usually on the same day as allergy immunotherapy (95120-95199) in standard medical practice. Therefore, these codes should not be billed together.

Policy: Place of Service Policies
Reference: AMA
Description: Certain procedure codes by definition are limited to particular place(s) of service. When these procedure codes are billed in a place of service inconsistent with the procedural definition, the code will be denied (e.g. hospital admission codes (99221-99223) can only be billed for place of service Inpatient Hospital or code 99295 (Initial Inpatient neonatal critical care) is an inpatient only procedure.

Policy: Multiple Procedure Reduction for Radiology
Reference: CMS
Description: CMS implemented new logic on January 1, 2006 that performs a multiple procedure reduction on specific radiology procedures. CMS’ rationale for implementing this logic is that when radiology procedures are performed on contiguous anatomical sites, that there is an overlap in resources associated to performing these procedures. CMS has identified 11 families of procedures that are similar by type of procedure (i.e. MRI, CT, and Ultrasound) and by anatomic site. When more than one code within a family is billed for the same date of service, then the technical component of the procedures with lesser Medicare prices will be reduced by 25%.

Policy: Multiple Endoscopic Procedures
Reference: CMS
Description: CMS has established payment guidelines when multiple endoscopic procedures are performed for the same date of service. Endoscopies can be classified as either “related” (e.g. 2 different upper GI endoscopies) or “unrelated” (e.g. an upper and a lower GI endoscopy]. The underlying concept of multiple endoscopy edits is that for each family of endoscopies (e.g. upper GI) there is a “base” endoscopy procedure which is considered to be a component of all other endoscopies within that family. In calculating the reimbursement for multiple endoscopies, the cost of the base endoscopy is deducted from the related endoscopy when the latter is not the endoscopy with the highest relative value.