(Medicare Claims Processing Manual)

Where CMS determines that nationally uniform temporary codes/modifiers are needed to implement policy/legislation between HCPCS codes updates, the codes/modifiers, definitions and policy are issued as Level II codes/modifiers prefixed with Q or K or G.  Questions may arise in updating that require A/B MAC (B) staff to refer to a physicians or suppliers pricing history.  Therefore, keep an electronic backup of HCPCS codes for the two prior years with linkages to pricing profiles.  Perform required computer analysis as necessary.   The HCPCS terminology seldom includes a place of service designation.  Where place of service affects pricing, pricing is obtained from the place of service field on the claim record.   A/B MACs (A) and (HHH) also develop editing screens using HCPCS based on payment and coverage policies from CMS.  A/B MACs (A) and (HHH) must assure that system claims processing complies with CMS policy and procedures.   20.9 - National  Correct Coding Initiative (NCCI)                                    (Rev.  10878, Issued: 07 -15-2021, Effective:08 -16-2021; Implementation:08 -16-2021)           The CMS developed the National Correct Coding Initiative (NCCI) program to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Associations CPT manual, CMS national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. An overview of the NCCI program for both the Procedure -to-Procedure (PTP), Medically Unlikely Edits (MUEs), Add- on Code (AOC) Edits and additional information sources are found on the CMS NCCI Website . The National Correct Coding Initiative Policy Manual for Medicare Services (also known as the Coding Policy Manual) shall be used by Medicare Administrative Contractors (MACs) as a general reference tool that explains the rationale for NCCI edits.  The purpose of the NCCI PTP edits is to prevent improper payment when incorrect code combinations are reported. The NCCI webpage contains separate tables of edits for physicians / practitioners, outpatient hospital services, and durable medical equipment. Additional information regarding types of tables is available in the How to Use The National Correct Coding Initiative (NCCI) Tools MLN booklet. The purpose of the NCCI MUE program is to prevent improper payments when services are reported with incorrect units of service (UOS). The CMS developed MUEs to reduce the paid claims error rate for Part B claims. An MUE for a Healthcare Common Procedure Coding System (HCPCS) /  Current Procedural Terminology (CPT) code is the maximum  UOS that a provider or supplier would report under most circumstances for a single beneficiary on a single date of service.  An AOC is a HCPCS / CPT code that describes a service that , with rare exception, is performed in conjunction with another primary service by the same practitioner. An AOC is rarely eligible for payment if it is the only procedure reported by a practitioner. CMS posted the Correspondence Language Manual for Medicare Services on the NCCI Website for use by the Medicare Contractors to answer routine correspondence inquiries about the NCCI PTP and MUE edits. The general correspondence language paragraphs explain the rationale for the edits. The section- specific examples add further explanation to the PTP or MUE edits and are sorted by edit rationale and HCPCS / CPT code section (00000, 10000, 20000, etc.). Please refer to the Introduction of the Correspondence Language Manual for additional guidance about its use.  20.9.1 - Correct Coding Modifier Indicators (CCMI) and HCPCS Codes Modifiers                                                                                                       (Rev . 10878, Issued: 07 -15-2021, Effective:08- 16-2021; Implementation:08- 16-2021)           The National Correct Coding Initiative (NCCI) File Formats continue to include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit file. This indicator determines whether an NCCI PTP-associated modifier causes the code pair to bypass the edit. The CCMI will be either a 0, 1, or a 9. The definitions of each are:  0 = an NCCI PTP -associated modifier is not allowed and will not bypass the edit. 1 = an NCCI PTP -associated modifier is allowed and will bypass the edit. 9 = The use of NCCI PTP -associated modifiers is not specified. This indicator is used for all code pairs that have a deletion date that is the same as the effective date. This indicator prevents blank spaces from appearing in the indicator field. 20.9.1.1 - Instructions for Codes With Modifiers ( A/B MACs (B)  Only)  (Rev. 10878, Issued: 07- 15-2021, Effective:08 -16-2021; Implementation:08- 16-2021)           A. General  Medicare Administrative Contractors (MACs) subject all line items for the same beneficiary, same NPI, and same date of service to National Correct Coding Initiative (NCCI) edits.  All line items for the same beneficiary, same NPI, and same date of service shall be subject to NCCI Procedure -to-Procedure (PTP) edits. If the CCMI of a PTP edit is 0, the Column Two code is not eligible for payment even if an NCCI PTP -associated modifi er is appropriately appended to one of the codes. If the CCMI of a PTP edit is 1, the edit may be bypassed and the Column Two code of the edit may be eligible for payment if an NCCI PTP-associated modifier is appropriately appended to one of the codes. I f the 2 codes of a code pair edit have the same NCCI PTP -associated anatomic modifier, the edit will not be bypassed unless an additional NCCI PTP -associated modifier is appended to 1 of the codes indicating the reason to bypass the edit. The use of modifiers that are not NCCI PTP -associated modifiers shall not bypass an NCCI PTP edit.  NCCI PTP -associated modifiers are the following:        Anatomic modifiers: E1 -E4, FA, F1- F9, TA, T1- T9, LT, RT,             LC, LD, RC, LM, RI     Global surgery modifiers: 24, 25, 57, 58, 78, 79  Other modifiers: 27, 59, 91, XE, XS, XP, XU     B. Modifiers 59 or -  X{EPSU}  Modifiers 59 or -  X{EPSU} and other NCCI PTP -associated modifiers shall not be used to bypass a PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI -associated modifier that is used. Find further information on modifiers 59 or - X{EPS U} in the Coding Policy Manual available on the CMS website.  Use of modifiers 59 or -X{EPSU} does not require a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifiers - 59 or - X{EPSU}.   Modifiers 59 or - X{EPSU} shall not be used with the following codes:   77427 Radiation treatment management, 5 treatments   Evaluation & Management (E&M) services  When a provider or supplier submits a claim for any of the codes specified above with the 59 modifier, the A/B MAC must process the claim as if the modifier were not present. In addition to those messages specified in 20.9.1 above, A/B MACs shall convey a dditional messaging per instructions in Pub. 100- 09, Chapter 6 and Pub. 100- 04, Chapter 22.  Examples of appropriate use of modifiers 59 and -X{EPSU} can be found in the Fact Sheet Proper Use of Modifiers 59 & - X{EPSU}.  1. Modifier 59 or XE are used appropriately when the procedures are performed in     different encounters on the same day.   2. Modifier 59 or XP are used appropriately when the procedures are performed by    different practitioners,   3. Modifier 59 or XS are used appropriately for different anatomic sites during the same     encounter only when procedures are performed on different organs, or different     anatomic regions, or in limited situations on different, non- contiguous lesions in different     anatomic regions of the same organ.   4. Other specific appropriate uses of modifiers 59 or - X{EU}  There are 3 other limited situations in which 2 services may be reported as separate and distinct because they are separated in time and describe non -overlapping services even though they may occur during the same encounter.  a. Modifier 59 or XE is used appropriately for 2 services described by timed codes provided during the same encounter only when they are performed sequentially. There is an appropriate use for modifiers 59 or XE that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If 2 timed services are provided in blocks of time that are separate and distinct (i.e., the same time block is not used to determine t he unit of service for both codes), modifier 59 may be used to identify the services.   b. Modifier 59 or XU is used appropriately for a diagnostic procedure, which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.  When a diagnostic procedure precedes a surgical procedure or on -surgical therapeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic procedure and is  not interspersed with services that are required for the therapeutic intervention; (b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; (c) it does not constitute a service that would have otherwise been required during the therapeutic intervention; and d) it is not specifically prohibited. If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately.   c. Modifier 59 or XU is used appropriately for a diagnostic procedure, which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow -up to the therapeutic procedure. When a diagnostic procedure follows the surgical procedure or non- surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure  and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post -procedure  diagnostic procedure is an inherent component or otherwise included (or not separately payable) post -procedure service of the surgical procedure or non -surgical therapeutic procedure, it should not be reported separately.   5. Modifiers 59 or X{EPSU} are used inappropriately if the basis for their use is that the     narrative description of the 2 codes is different.