Packaged Services and NCCI Edits What ASCs need to know BY ROBERT KURTZ


wo coding concepts that ASC cod- ers should understand to make cer-

tain they are billing Medicare correctly are packaged services and National Correct Coding Initiative (NCCI) edits. “It is critical for ASCs to understand both if they want to receive correct payment and limit denials,” says Cristina Bentin, president of Coding Compliance Man- agement in Baton Rouge, Louisiana.

Packaged Services Packaged services is a feature of Medicare’s Outpatient Prospective Payment System (OPPS), says Robert Lathrop, certified coder and compli- ance auditor for The Coding Network, a provider of coding services based in Beverly Hills, California. “Certain procedures may have an N1 ASC pay- ment indicator. What that means is the payment of that surgery or procedure is packaged into a major procedure performed at the same time.” There are many Current Procedural

Terminology/Healthcare Common Pro- cedure Coding System (CPT/HCPCS) codes that are listed as an N1 payment indicator by Medicare, Bentin notes. “ASCs need to check CMS’ ‘Addendum AA—Final ASC Covered Surgical Pro- cedures for CY 2015 (Including Surgi- cal Procedures for Which Payment Is Packaged)’ so they know procedure, ser- vice and supply reimbursement expecta- tions and those that are packaged with no additional reimbursement. Under- standing that packaged services won’t generate additional reimbursement will prevent wasted time on the back end fighting for additional payments.” She adds, “Understanding which procedures are listed as an N1 can also assist with case costing and determin- ing whether to perform a procedure or not.” The complete listing can be found at

26 ASC FOCUS APRIL 2015 NCCI edits are updated quarterly,

and available for free on the Medi- care website at www.ascassociation. org/2015PackagedCodes. While Medicare and certain other

payers follow the NCCI edits, many commercial payers are not required to do so and might follow other guide- lines, Lathrop says. “Another set of directives pay-

ers may follow are those developed by the American Medical Association (AMA),” he says. “AMA works closely with many specialty societies when developing coding directives which, at times, vary from the NCCI edits.” Specialty societies might provide

NCCI Edits

Medicare implemented NCCI to ensure consistent, national correct cod- ing methodologies and to minimize improper coding that could potentially lead to inappropriate reimbursement, Bentin explains. Medicare issues NCCI edits—pairs of codes that are not sep- arately payable except under certain circumstances—to its claims payment processing system to prevent improper payments when such incorrect code combinations are reported. “For example, certain shoulder pro- cedure combinations may not be sep- arately reported when performed on the same anatomic structure (ipsilat- eral/same side),” she says. “However, understanding the NCCI edits, its mod- ifier meanings and applications lets the user know that some shoulder code pairs allow separate reporting when performed on the opposite side (i.e., opposite shoulder). Medicare’s NCCI Policy Manual for Medicare Services provides written directives that, when paired with its NCCI Edits tables, can ease the decision-making process.”

reporting directives independent of Medicare and AMA, Bentin says. “There can be instances when there is limited payer, AMA or Medicare directive for a specific reporting sce- nario. ASCs should understand that NCCI edits do not include all possible combinations of correct coding edits, but they are still required to code cor- rectly and use credible resources. ASCs tend to forget to review the spe- cialty societies’ recommendations in the absence of Medicare, AMA and payer directives.” It is imperative for ASCs to learn

what rules their payers follow before the coding of a procedure is com- pleted, Lathrop advises. “This can drastically affect what procedures you are allowed to bill for and, ulti- mately, your payment.” It is the facility’s responsibility

to verify and ensure correct report- ing of its surgical procedures based on its payer’s specific directives, Lathrop adds. “This should be done when the ASC enters into a new con- tract with a payer as it will make the whole process easier.”

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