LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


Corporate

Print | Bookmark | Email | Font Size: + |

December 5, 2014

National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs)

At a national level, Medicare identifies individual services that are components of more inclusive services using National Correct Coding Initiative (NCCI) edits. NCCI edits are designed to promote correct coding and prevent improper payments by "bundling" component codes into the more inclusive code. Component services that are billed separately from the more inclusive service are denied, unless an exception applies. This is one of the top reasons for denial of Medicare Part B services.

Here are some steps you can take to prevent NCCI denials:

  • First, know if NCCI edits apply to the services you are submitting. Code pairs are listed on the CMS website and may be updated as often as quarterly.
    • Codes are designated as Column I or Column II codes. Most of the time, the "parent" code is in Column I and component code in Column II. For some code pairs, the Column I and II codes are considered "mutually exclusive" and should not be reported together (for example, a vaginal hysterectomy and total abdominal hysterectomy).
    • If both codes from a Column I and II code pair are submitted, the Column I code may be reimbursed and the Column II code will not be reimbursed.
  • Second, if an NCCI edit applies to your services, determine whether you have an exception to the NCCI edits as noted by the Modifier Indicator assigned to the code combination. (No exceptions are allowed if the modifier indicator is 0.) There must be documentation in the patient's medical record to support all exceptions.
    • Note: denials based on NCCI edits are coding denials, not medical necessity denials; therefore, it is not appropriate to issue an Advance Beneficiary Notice of Noncoverage (ABN) to shift liability to the beneficiary.
      Modifier Indicator Explanation Example
      0 Codes are always bundled; do not submit a modifier for exceptions CPT codes 43235 (EGD) and 31505 (laryngoscopy)
      1 Exceptions may apply; submit the appropriate modifier. (Note: documentation is required in the patient's medical record.) CPT codes 94620 (pulmonary stress test) and 94010 (spirometry)
      9 Not applicable. The code pair is no longer bundled and no modifier is needed for purposes of noting an NCCI exception. CPT codes 97001 (PT evaluation) and 99354 (prolonged eval., office)

Exceptions may include services that were performed:

  • At different (separate) encounters
  • On different anatomic sites
  • As distinct services (use caution when identifying "exceptions" for this reason, as errors are frequently noted with this usage)
    Do you have an exception to the NCCI edit? Steps
    No (services are correctly bundled)
    • Do not submit the component service. It is incorrect to submit separate codes ("unbundle") when a service is correctly represented by a single, comprehensive code.
    Yes (services should not be bundled)
    • Identify the correct modifier to submit with the component code to signify that an exception applies. The CGS Modifier Tool provides some guidance.
    • Know that CPT modifier 59 may be used to note an exception to National Correct Coding Initiative (NCCI) edits, if no other "exception" modifier applies. For this reason, CPT modifier 59 is often the "modifier of last resort" to note an exception to NCCI edits or other bundling edits.
      • Important: maintain supporting documentation in the patient's medical record.

Guidance: Appropriate and Inappropriate Use of CPT modifier 59

  • If another, more specific modifier exists that is more appropriate and describes an exception to an NCCI edit, use the more specific modifier, not CPT modifier 59. Guidance on documentation and correct modifier submission is available in the CGS Modifier Lookup Tool.
  • CPT modifier 59 may be appropriate when two procedures that would otherwise be bundled are performed on different anatomic sites or during different patient encounters. Documentation in the patient's medical record must support use of this modifier.
  • Different diagnoses are not necessarily required. The keys are anatomic sites and patient encounters.
  • Refer to CMS MLN Matters article SE1418External PDF, "Proper Use of Modifier -59," for specific examples of appropriate and inappropriate use of CPT modifier 59.
  • If your claim was denied as a duplicate, but the two (identical) services are "separate and distinct" and no other modifier applies, CPT modifier 59 maybe appropriate.

Future update: for dates of service on or after January 1, 2015

CMS has established four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of CPT modifier 59. For dates of service on or after 1/1/2015, you may submit the X HCPCS modifiers (XE, XS, XP, and XU) if you are currently using CPT modifier 59 for a reason within the published definition of the X HCPCS modifiers. You also have the option to continue using CPT modifier 59 until CMS issues examples of circumstances in which the X HCPCS modifiers are or are not appropriate. For more information, see CMS MLN Matters Article 8863External PDF, "Specific Modifiers for Distinct Procedural Services."

Medically Unlikely Edits

"Medically Unlikely Edits" (MUEs) are a separate set of NCCI edits designed to identify the maximum number of units that would normally be performed by a provider on a single date of service. These are not "frequency parameters" – these edits are designed to prevent billing errors that result from entering an incorrect quantity for services.

  • Most MUEs are available on the CMS websiteExternal website and may be updated as often as quarterly. MUE changes are not retroactive unless the change is to update the file with a retroactive date.
  • MUE denials are coding denials, not medical necessity denials; therefore, it is not appropriate to issue an Advance Beneficiary Notice of Noncoverage (ABN) to shift liability to the beneficiary.
  • Before you submit claims for injected drugs, pay special attention to the quantity; look at the specific HCPCS code and the number of units associated with that code. For example, HCPCS code J1020 is for "injection, methylprednisolone acetate, 20 mg." If you administered 20 mg to the patient, the quantity billed on your claim should be 1, not 20.
  • If the number of services you submitted is correct and reflects medically necessary care provided to the patient, and your claim is denied based on an MUE, you may appeal the denial. Keep in mind that first-level appeals (Redeterminations) must be submitted within 120 days of the date of the initial determination (i.e., date on your Remittance Advice). Include supporting documentation with your request. Redeterminations may be submitted electronically through our secure web portal, myCGS, or on paperPDF (tip: complete the form electronically, then print, sign, attach supporting documentation, and mail).
  • The MUE Adjustment Indicator (MAI) provides the rationale for the edit:
    MAI Explanation
    1

    Claim line edit

    2

    Absolute date of service edit; "per day edits based on policy"

    • CGS will not pay in excess of an MUE value with MAI indicator 2
    3

    Date of service edit: "per day based on clinical benchmarks"

If You Disagree with an NCCI or MUE Edit:

  • To request a reconsideration of an NCCI edit, follow the instructions on the CMS NCCI web pageExternal PDF.
  • To request a reconsideration of an MUE value, send your request, the rationale, and any supporting documentation, to:

    National Correct Coding Initiative
    Correct Coding Solutions, LLC
    PO Box 907
    Carmel, IN 46082-0907
    Fax: 317-571-1745

Reference:

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved