NCCI Edits explained

In 1996, CMS Implemented National Correct Coding Initiative (NCCI). 

It has 2 major goals:      

 - To promote physician and provider compliance with medicare diagnosis and procedure coding guidelines.

  -   To ensure appropriate payment (reimbursement) for physician and provider services.

NCCI edits identify invalid diagnosis codes such as (ICD-9-CM) E codes, and discrepancies between the diagnosis and the patient’s age or sex. For eg, a claim submitted for a male patient with a code for ovarian failure or a female patient with prostate hypertrophy, will be returned to the provider without payment.

NCCI edits identify following types of procedure coding errors:

1.       Mutually Exclusive Procedures:- reporting 2 procedures that cannot possibly be performed at the same time, such as laminectomy (removal of the bony arches of a vertebrae) and total hip replacement.

2.       Component part coding:- submitting separate or multiple codes for a procedure that is covered by a single code, such as reporting a separate code for a laprotomy (incision into abdomen) that was done as a part of appendectomy.

3.       Unbundling:- submitting separate or multiple codes that are part of a global surgery package such as routine post operative surgeries.

4.       Invalid Modifier:- assigning a wrong modifier to the CPT or a HCPCS Level II code. For eg. 52, Reduced Services applies only to procedure/services provided on an inpatient basis and may not be assigned to outpatient or ASC procedure codes.

Revenue codes

Revenue Code and Description:

DEF:   Revenue codes are 3-digit numbers that are used on hospital bills to tell the insurance companies either where the patient was when they received treatment, or what type of item a patient might have received as a patient. A medical claim will not be paid if this is missing from a bill.

Revenue codes go along with procedure codes. When putting them in a charge master, you would add the correct revenue code to the CPT code you were going to use for a particular department. It's the use of revenue codes which allows hospitals to use the same CPT code in multiple departments because it will show which department the services were provided in.

When a UB-92 is generated, the hospital billing software (charge master) enters the revenue code in FL 42. A narrative description of the revenue code is simultaneously entered in FL 43. The billing specialist reviews the revenue codes and descriptions to determine if entries are complete and accurate.

When the insurance carrier requires a 4 digit entry in this field, the first digit is always 0. The last entry in FL 42-43 is always revenue code 001 with the description TOTAL CHARGES in FL43 which must be equal to the sum of both covered and non covered charges. There are nearly 1,000 revenue codes that are used by insurance carriers.

Revenue codes are divided into 2 categories: accommodation codes and ancillary services codes.

1.       Accommodation codes:-   Identify the type of bed such as medical/surgical, pediatric or psychiatric – that the patient occupies in a hospital room. A hospital room is classified as follows: private, a single bed room; semiprivate 3 or 4 beds per room; and ward 5 or more beds per room. Room and Board charges/rates vary by room classification and type of bed. A private room in an intensive care unit (ICU) will have higher room rate than a ward in a medical/surgical unit. The room and board rates includes items and services such as routine linens, towels, night gowns, meals and routine nursing care associated with the specific unit. Below table lists some of the accommodation revenue codes with descriptions:

Accomodation revenue codes (FL42)	Definitions
114	Psychiatry, private room
116	Detoxification unit, private room
120	General medical, semiprivate room
121	Medical/surgical(GYN), semiprivate
122	Obstetrics(OB), semiprivate
123	pediatric, semiprivate room
124	Psychiatric, semiprivate room
151	medical/surgical, gynecology ward
171	Newborn nursery, Level I, routine newborn care
174	Newborn nursery, Level IV, newborn intensive care
201	Intensive care unit (ICU), surgical care
206	Intermediate intensive care unit, post ICU, also called as step down
211	Coronary care unit(CCU), myocardial infarction care
212	coronary care unit, pulmonary care
213	Coronary care unit, heart transplant care

1.       Ancillary service revenue codes:-   identify services and supplies that are not included in the room and board charges. Items and services such as egg-crate mattress, pharmacy, laboratory tests and radiology services are separate entries on FL 42 and 43. Below table lists some of the ancillary service revenue codes with descriptions:

Ancillary service revenue codes (FL42)	Description
250	Pharmacy, general
258	Intravenous (IV) solutions
274	Prosthetic device
301	Lab/Blood chemistry tests
306	Lab/Bacteriology and microbiology blood tests
311	Lab/Pathological, cytology, laboratory test on cells
312	Lab/Pathological, histology; laboratory tests on tissue
314	Lab/Pathological, biopsy
321	Radiology/diagnostic, angiocardiography
322	Radiology/diagnostic, arthrography
324	Chest X-Ray
331	Radiology/Therapeutic, chemotherapy - injected
333	Radiology/Therapeutic, radiation therapy
341	Nuclear medicine, diagnostic
342	Nuclear medicine, therapeutic
352	Computerized tomography(CT) scans, whole body
360	operating room services
370	Anaesthesia, general
402	Other imaging services, ultrasound
421	Physical therapy visit
710	Recovery room
730	EKG/ECG

Within most revenue code categories there are subcategories that better define what's going on or what was being used. For instance, revenue code 270 is the general code for supplies. But within that category are nine subcategories:

271 - Nonsterile Supply

272 - Sterile Supply

273 - Take-Home Supply

274 - Prosthetic/Orthotic Devices

275 - Pacemaker

276 - Intraocular Lens

277 - Oxygen Take-Home

278 - Other Implants

279 - Other Supplies/Devices

Every revenue code category has a subcategory that ends in "9" to denote items that don't fit a specific revenue code.

EXAMPLE:

1)      Jane reviews the UB – 92 for a patient who underwent a total hip replacement. She notes that a general anaesthesia revenue code (370) and an operating room service code (360) are listed in FL 42 and 43. A code for recovery room services is not included on the UB – 92. Jane knows that a general anaesthesia code should be billed with a recovery room code (710). Jane puts on hold the claim and notifies the surgical department that a recovery room revenue code is needed. Surgical department staff enters the revenue code. Jane retrieves the UB-92, completes the editing process and releases the claim for submission.

2)      CPT code 99282, which is for an emergency room visit of low to moderate severity, and revenue code 450, which stands for emergency room. In this case, revenue code 450 is the only code that could be used for this CPT code, thus making this one easy to code.

3)      A more complex example to use would be something like CPT 12001, which is a simple laceration repair of a wound on the scalp, trunk of the body, or the extremities such as hands and feet. This procedure could be done in multiple places. It could be done in the OR as part of another procedure; that would be revenue code 360. It could be done in the emergency room; revenue code 450. It could be done in a treatment room; that would be revenue code 761. It could be done in a clinic; that would be revenue code 510. There are at least 3 other revenue codes where this procedure could be performed.