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CMS NCCI Edits Effective July 1


ALERT!  Medicare Contractors to Automatically Reprocess Denied Claims Tied to NCCI Edits

Academy Communication — Sept. 20, 2013

The Centers for Medicare and Medicaid Services has announced that Medicare administrative contractors will reprocess denied claims related to National Correct Coding Initiative (NCCI) edits implemented on July 1. No action is required by ophthalmologists for the claims to be reprocessed. The denials are the result of a computer system issue that fails to recognize the appropriate modifiers (-24, -25, -57). The new edits apply to any global surgical code billed with an established patient eye-visit code appended with one of the appropriate modifiers. CMS indicates that the denied claims will be reprocessed by Nov. 15.

For more information, contact the Academy’s Governmental Affairs Division at 202.737.6662.


CMS Releases Plan to Resolve Denied Claims Tied to NCCI Edits

Washington Report Express — Aug. 22, 2013

In response to the Academy’s lobbying efforts, the Centers for Medicare and Medicaid Services has released a plan to resolve denied claims related to National Correct Coding Initiative (NCCI) edits implemented on July 1.

According to CMS, the denials are occurring as a result of a computer system issue that fails to recognize the appropriate modifiers (-24, -25, -57). The new edits apply to any global surgical code billed with an established patient eye-visit code appended with one of the appropriate modifiers. The agency said it will stop applying the new edits for all surgical codes to work on a permanent solution beginning on Oct. 1; the solution will be retroactive to July 1.

If your Medicare Administrative Contractor has a temporary fix to the computer issue in place, you may submit claims and they should be processed normally. However, if your Medicare Administrative Contractor has not implemented a temporary fix, CMS said that ophthalmologists may hold claims until Oct. 1, at which time those and others that have been inappropriately denied may be submitted or resubmitted for payment.

The Academy, with input from the American Society of Retina Specialists, continues to work directly with CMS on a permanent resolution. In addition, the Academy is working with Medicare Administrative Contractors through its Carrier Advisory Committee liaisons to implement temporary fixes before Oct. 1. So far three contractors have implemented temporary fixes: First Coast Service Options, Inc.; Noridian Healthcare Solutions, LLC; and Wisconsin Physician Services Insurance Corporation.

For more information, contact the Academy’s Governmental Affairs Division at 202.737.6662.


Academy Investigating Medicare Carriers’ Denial of Claims that Use New NCCI Edits for Minor Procedures

Washington Report Express — July 25, 2013

The Academy is looking into member reports that Medicare carriers across the country are denying some provider claims that use new National Correct Coding Initiative (NCCI) edits that were implemented on July 1 by the Centers for Medicare and Medicaid Services. The new edits bundle established patient evaluation and management and eye-visit codes with all surgical procedures that have either a zero, 10- or 90-day global period. CMS recognizes in a letter to the American Medical Association, however, that there are clinical situations in which a patient may be separately examined while having a procedure on the same day. An edit designated as “1” indicates that an exam may be unbundled from the surgical procedure if both services are medically necessary.

Reports of denials to the Academy relate specifically to modifier -25, which is used for unbundling when a minor procedure is performed. In order to use this modifier, the exam must be significantly, separatelyALERT identifiable from the procedure if it is performed on the same day. An exam performed solely to confirm the need for surgery is not separately billable on the same day as a minor procedure. Options available to providers until CMS and Medicare carriers provide guidance on what to do with claims with modifier -25 include: submit claims and appeal/resubmit if denied; or submit the procedure code and hold the exam code (e.g., for intravitreal injections, submit for the injection and the drug).

In initial conversations with carriers to resolve the denials, the Academy has learned that implementation of the new edits requires significant modifications to the carriers’ claims processing systems. The Academy continues to work to resolve the claims denials, which appear to be limited to modifier -25. The Academy has not been notified of any denials related to major procedures and exams, which use modifier -57 and -59. Some carriers have recommended using modifier -59 with an exam and minor procedure; however the Academy believes this would be incorrect and could cause future problems, including post-payment claims review.