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Over the years medical billing and coding has evolved. We have moved from an industry based heavily on manuals, paper records, and bills to electronic billing and coding software. In doing so, we have relied so heavily on software, that we now utilize the software and the tables to recommend when to attach a modifier to codes in order to override an edit or error. However, is there more to it than that?

In our webinar we will learn about the manual that is behind the edits. Do you bill for shoulder surgery or knee surgery? What about chiropractic treatment? How about physical or occupational medicine? How about drug testing services? If you think that for shoulder a limited debridement was in a different area so a modifier is needed to report with the rotator cuff, don’t be so sure. If billing for re-evaluations in physical therapy or occupational therapy, be careful that there are no patterns and that there is more documentation than just a certifying for more visits. If drug testing is reported as 80320 through 80377 for the definitive drug testing and you’re receiving a denial, it may not be a coverage issue or patient responsibility. It may actually be an invalid code or codes! Have you ever wondered why a new patient evaluation requires a modifier 25 when performed in conjunction with a procedure when the provider has never seen the patient previously and there is no established provider-patient relationship?

These are coding scenarios and questions that the 200+ pages manual address. This manual is often based on standards of clinical practice, clinical data, AMA CPT® Manual guidelines, code definitions, or other CMS policies. However, over the years, many payers have adopted this manual to fit their reimbursement policies with further edits to accompany their medical policies or benefit plans. Due to the Affordable Care Act, Medicaid plans have been required to implement these edits, which have been in place for nearly a decade.

Unlike the edits, which undergo quarterly updates, the manual only gets revised yearly. The yearly updates to the manual are often minor unless there are any major coding changes to a particular section or a new policy implemented. Many of the coding software programs include these manuals or links to the manuals for the coders and billers to utilize, but it also depends how well we know the software, training we have received on it, and the billing, coding, or audit metrics in place by employers whether or not staff utilize the manual.

Throughout this course, we will dive into the manual, and really look at some key elements that cause some of the greatest coding errors or risks for audits and denials by payers or regulators. By understanding this manual and its use, we also have the ability to better educate our providers about documentation, query them for clarification where needed in their records, write appeal letters targeted to the edits or denials based on the modifier, and submit clean or corrected claims where necessary for better more accurate coding and accounting practices.

Learning Objectives:

• Understand the policies behind the tables and when a modifier truly is or is not allowed
• Review major sections of the manual and key portions that generate a larger percentage of audits and denials by payers
• Finding information that could better support coding or billing practices during appeals
• Incorporate any new coding or billing practices that could improve timely reimbursement
• Avoiding claims denials and streamline your reimbursement process
• To review the overall development of the NCCI edits
• To appreciate how physicians and hospital should use modifiers in connection with the NCCI edits
• To review the general and specific policies inherent in the NCCI guidelines
• To identify the differences in coding policies between physicians and hospitals
• To appreciate the compliance issues surrounding physician and hospital use of modifiers
• To review policies relative to specific service areas as delineated in CPT

Areas Covered in the Session:

• The policies behind the edits
• Key areas of focus by payers for common coding and billing errors
• Where to find the manuals and how to use them in your practice
• The 3 types of NCCI edits: PTP, MUEs, and Add-on Codes
• Which edits apply to which provider types despite one policy manual
• The functions of the different indicators
• Hidden edits that exist but not explicitly stated in either the manual or the tables
• Medicare vs. Medicaid NCCI Edits the differences between the government programs
• Use of Modifiers with the NCCI Policies
• Most recent NCCI procedure bundles to slash PTP denials
• Medically Unlikely Edits (MUEs)
• Live Q&A session

Suggested Attendees:

• Healthcare Administrators
• Coders
• Billing and Claims Transaction Personnel
• Chargemaster Coordinators
• Financial Analysts
• Compliance Personnel
• Physicians
• Internal Auditing Staff and Other Interested Personnel
• Revenue Cycle Management (RCM) Companies
• Hospitals and Other Facilities
• Clinical Labs
• Ambulatory Surgery Centers
• Payers
• Practice Managers
• Collection Companies
• Air Ambulance Providers
• Ground Ambulance Providers
• Supplemental Wrap Networks
• State Policy Analysts
• Actuaries
• Data Scientists

Presenter Biography:

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This is a Live Virtual session.

A new way of immersive learning that allows you to engage live with our instructor and peers providing you with the flexibility to juggle the new work-life balance.

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Snippet From Our Previous Session