Lynn Thornton, RHIA, CCS
The health information industry is packed with opportunities for those professionals willing to work hard to expand their skills. I’ve created my own opportunities in the health information management world by becoming a subject matter expert (SME) in regulatory concepts. This is not a self-appointed title; it is one that has been bestowed upon me by various HIM Directors, Managers and CFOs. This skill set has set me apart from coders with the same level of expertise I have, and, it has made me seem like a more valuable staff member and/or consultant.
The best part about this story is this knowledge and competency is free to anyone who seeks to attain it. If I could change anything about our education for new coders, or ongoing education in the hospital setting it would be to include strong education in these regulatory concepts. This education should be part of the post audit process during which the coder learns not only coding concepts they were deficient in, but also the background regulatory knowledge’s and competencies to work through denied claims.
Listed below are some of the resources I use in the denials management process. As an auditor and coding educator I use these and many more reference materials in conducting research and providing coding guidance. Coders may use this brief information as a start toward regulatory competency.
| NCCI Edit Tables | NCCI Edit Tables |
| PTP Edits | Coders must have skills in resolving procedure to procedure (PTP) edits. There are no other staff members in the hospital with the skill required to complete this task. And, contrary to what many coders think, passing it off to another department will not result in the edit being resolved. CMS has provided an introduction to PTP edits and it may be found at this URL: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html |
| Coders should also review the document, How to Use The Medicare National Correct Coding Initiative (NCCI) Tools. This document covers the critical elements of the NCCI edits. If you are new to the use of the NCCI edits, carefully review this document. Coders must have a solid knowledge and competency in this area. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/How-To-Use-NCCI-Tools.pdf | |
| MUE Edits | Medically Unlikely Edits (MUE) are not as common as the PTP edits but they are still a major area of coder knowledge deficit. CMS has provided an introduction to MUE edits and it may be found here: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html |
| There are MUE edits tables for Practitioners, facilities and durable medical equipment (DME). All of these resources are found as related links here: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html | |
| Add On Code Edits | Add-on code errors are a direct result of coder error which should not have occurred. Access the introduction to the add on code edits at the URL below. Note at the bottom of this webpage is a complete file on Add-on Code Edits for 01/01/2018. As changes may be made during the FY, always assure the most up-to-date file is being accessed. https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Add-On-Code-Edits.html |
Ideally, all edits will be resolve prior to the coder concluding their work on an encounter. Additionally, clicking “compute” on the encoder does not complete the claim. If an edit is present, the entire claim sits open in the business office pending edit resolution. It is best practice for any claims with unresolved edits be returned to the coder for resolution. It is those very claims which may sit unresolved and finally hit the timely filing deadlines.
All coders, whether inpatient and/or outpatient should be skilled in researching the National Coverage Determinations and/or Local Coverage Determinations when called upon to do so. These coverage determinations may be applicable to both inpatient and outpatient services. Medicare provides an educational document intended to assist users in working through accessing and interpreting the information on this resource. The following information is available to assist in this endeavor.
| Resource: | Notes |
| Indexes to NCDs and LCDs | This is the main access to the NCDs and LCDs. Follow the directives on the webpage to access the correct data. https://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx |
| Welcome to Medicare Coverage Database | This webpage has an introduction to the CMS NCDs and LCDs. If you lack competency in this area this guidance will be of great assistance. https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?id=209 |
The CMS Medicare Physician Fee Schedule (CMS MPFS) is a critical resource for coding in hospitals and physician offices. Coders should use this resource to determine the work relative value unit (wRVU), multiple procedure indicators, bilateral surgery indicators, assistant surgeon indicators and much more.
| Resource: | Website URL |
| CMS MPFS | https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/ |
I love regulatory research. It is my pleasure to assist facilities in claim denial resolution, however, best practice is for a coder to become proficient in this area themselves-it just takes a little time and effort. Time and effort well spent!