July 13, 2009

You may have started receiving unexpected denials from Medicare for epidural injections and nerve blocks performed together with a number of invasive monitoring line insertions and injection/aspiration procedures. THESE DENIALS MAY BE WRONG, according to a response received by the American Society of Anesthesiologists (ASA) questioning the change that “bundled” the procedures.

Unfortunately, the Medicare carriers will continue to reject claims for bundled pain codes until they receive the next version of the data files from the Centers for Medicare and Medicaid Services (CMS) for implementation on October 1, 2009. You have two options for receiving the proper payment amount, both of which are disruptive but inevitable at this point:

1. Hold your affected claims and submit them to your carriers after October 1, 2009, or
2. Keep track of all the bundling denials for services provided between April 1, 2009 and October 1, and resubmit the affected claims or appeal the denials after October 1.

How did this happen? Many if not all of you will recognize the name “National Correct Coding Initiative” (“NCCI,” “CCI”). Since 1996, the Medicare carriers have run physician claims for multiple procedures performed on the same patient, on the same date of service, against the CCI lists of prohibited code pairs. The NCCI’s principal tool is the Column One/Column Two Correct Coding Edits table. Column One lists “comprehensive” codes or other codes frequently billed together with an inappropriate code in Column Two; “Column Two” codes are those that are considered a component of the associated Column One codes and should not normally be reported separately or “unbundled.” If a claim contains a pair of codes for which there is a CCI edit, the Column Two code is denied unless it is submitted with a CCI associated modifier, e.g. -59 (distinct procedural service) and the edit in question allows such modifiers. Some CCI edits do not allow payment for the Column Two code under any circumstances, but many do. Those that never allow the Column Two code to be unbundled are identified with the indicator “0” while those that allow the edit to be bypassed and both procedures to be paid use the indicator “1.” For more information on the CCI and its system of edits, consult the Overview and links of interest on the CMS website.

CMS updates the CCI every quarter, based on new codes or new analyses of coding practices, following consultation with various internal and external advsisors, as well as with the medical specialty societies. The proposals for CCI changes that were implemented on April 1st had been reviewed by more than 100 national healthcare organizations, according to the NCCI contractor’s letter to ASA. Retroactive reversals such as the one just made are nevertheless not uncommon because thousands of codes are reviewed in and as groups.

At the carrier level, however, eliminating edits that have been reversed or withdrawn must await the release and installation of the next version of the NCCI data tapes – in this instance, NCCI version 15.3 by October 1st.

In version 15.3, nerve blocks and epidural injections will continue to be separately payable, as long as they are submitted with the appropriate modifier (typically modifier -59) that will deactivate the CCI edit. Use of the modifier will signal the carrier to allow the claim for the epidural or nerve block submitted with the Column One codes in the table below. Version 15.2, currently on the carriers’ computers, does not recognize the modifiers or allow the edit to be bypassed.

Version 15.3

Also in version 15.3 of the NCCI, CMS has deleted edits introduced in April that deny epidural injections and nerve blocks reported together with any of the following procedures:

• Emergency intubation - 31500
• Insertion of non-tunneled central venous access/catheter - 36555-36556
• Insertion of arterial line - 36620-36625
• Insertion of Swan-Ganz catheter – 93503

Claims submitted prior to October 1st for these pairs of procedures will be erroneously denied by Medicare, if the services are performed between April and October. They will be payable retroactively to April 1st after October 1, 2009, thanks to ASA’s efforts. (ASA challenged several other edits bundling conscious sedation codes with certain central and peripheral venous access codes; the NCCI contractor’s response to these objections and its reversal of new edits affecting several other codes rarely performed by anesthesiologists is available on the ASA web site.)

Private payers may choose to use or ignore the CCI edits – or worse, they may create their own prohibited code pairs and perhaps not even disclose the edits before denying claims. One major private payer appears to be denying payment for fluoroscopy performed with pain procedures, and for anesthesia provided for a pain procedure performed by another practitioner. It also seems that payers recycle edits – they may give up the battle to enforce a particular edit only to revive the policy denying payment several years later.

The best solution for handling private payer code paid edits is to track them by payer and to challenge them, if your participation agreement doesn’t provide for them. Adjust your expected collections accordingly. ABC constantly monitors claims for the emergence of new edits and appreciates clients’ additional vigilance.

As for the CCI edits currently rejecting claims for pain procedures performed with the procedures described above, we will be noting clients’ claims that need to be submitted, resubmitted or appealed after October 1st, and we encourage everyone to make sure that they ultimately receive the full payment to which they are entitled.

As always, we welcome your feedback. If you have a question about this topic or if you have another topic you would like discussed, please let us know.