Lynn Thornton, RHIA, CCS
Coding is an exacting process that requires critical thinking. It is also a process that requires access to high level resources for validation of information that may be essential to the coding process. The resources for ICD-10-CM and CPT/HCPCS should all be well known to the coder and must be consulted on a daily basis in the coding process. Edit clearance and denial resolution may require a higher level of information as provided by the following sources.
CMS Medicare Physician Fee Schedule: This is an invaluable resource as it provides multiple elements for review on CPT codes including, but not limited to the following:
- Work Relative Value Unit
- Bilateral Surgery Indicator
- Multiple Surgery Indicator
- Global Fee Period Indicator
- Assistant Surgeon Indicator
- Co Surgeon Indicator
- Physician Supervision Indicator
CMS Claims Processing Manual Chapter 12 –Physicians/Nonphysician Practitioners and any other Claims Processing Manuals specific to the Coding and Billing process: For coders and auditors this is the last stop many times in fighting a claim denial. This resource contains the information that provides the background information for billing of physician and mid-level claims that we typically need in claims resolution. It also provides resources we may not always consider as essential including, but not limited to, the following:
- Medicare Physicians Fee Schedule Overview
- Correct Coding Policy
- Surgeons and Global Surgery
- Teaching Physician Services
- PA Services Payment Methodology
- NP and CNS Services Payment Methodology
NCCI PTP Edit Tables: The basis of edit resolution is on these tables. There is not guess work and if a coder and/or auditor use these tables correctly, a quick, clean claim should result. The edit tables provide four critical elements for the coder and a very brief overview for the edit tables is as follows:
- Column 1 codes: These codes will always be paid.
- Column 2 codes: These codes may or may not be paid depending on the edit indicator and PTP edit rationale.
- Edit Indicator: The edit indicators provide insight as to whether or not a modifier may be applicable.
- PTP Edit Rationale: The 14 edit rationales provide a statement as to the bundling of a service.
NCCI Edits General Correspondence Language and Section–Specific Examples (for NCCI Procedure to Procedure PTP Edits and Medically Unlikely Edits (MUE)): Many coders and sometimes auditors despair at not understanding the PTP edit rationale on the NCCI PTP Edit Tables. Many of us guess as to the meaning of that rationale. We can take the guesswork out of the equation and start to code with real accuracy when we consult this resource which provides the background information as to what the edit rationales mean. This resource also includes section specific examples. Consult this resource and the coder/auditor will find guidance on the following:
- Standard preparation/monitoring services for anesthesia
- HCPCS/CPT procedure code definition
- CPT Manual or CMS manual coding instruction
- Mutually exclusive procedures
- Sequential procedure
- CPT “Separate procedure” definition
- More extensive procedure
- Gender-specific procedures
- Standards of medical/surgical practice
- Anesthesia service included in surgical procedure
- Laboratory panel
- Deleted/modified edits for NCCI
- Misuse of column two code with column one code
- Medically Unlikely Edits (MUE) (Units of Service)
- Deleted/modified edits for MUE
NCCI MUE Edit Tables: MUE edits are not as common a problem for coders and auditors and the rationale is not as difficult to understand. For almost all services there is a limit on the number of units that are reportable for DOS. The same may be said of supplies and drugs. When that limit is exceeded, an MUE edit is generated. The edit rationales are listed above in the NCCI Edit Correspondence Language discussion.
National Coverage Determinations and Local Coverage Determinations: The NCDs/LCDs are an important resource for coders and auditors. While the guidance in these directives is applicable to Medicare and Medicare Advantage Plans, most commercial payers follow CMS guidance in this regard and use these directives as a basis for their own denials. Consult this resource when a denial occurs that has been linked to this source.
If a coder will use the guidance provided in the resources listed in this document their coding will improve and their level of understanding of the coding editing process will be enhanced.