February 24, 2017

CMS Denies Appeal of NCCI Edit Guidelines in 2017 Manual

The Centers for Medicare and Medicaid Services has ruled against a multi-society appeal led by the American College of Radiology (ACR) that questions the appropriateness of several new statements and revisions appearing in the 2017 National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services.

CMS informed the ACR and allied professional societies in a January 18 letter that it has affirmed that its 2017 manual guidance is appropriate and reflects current CMS policy. However, CMS will review these sections again during the 2018 version of the manual.

The issues appealed by the multispecialty societies included the following sections of the NCCI Policy Manual (listed in italics):

Chapter IX-6, #3: When a comparative imaging study is performed to assess potential complications or completeness of a procedure (e.g., post-reduction, post-intubation, post-catheter placement, etc.), the professional component of the CPT code for the post-procedure imaging study is not separately payable and should not be reported. The technical component of the CPT code for the post-procedure imaging study may be reported.

Chapter IX-8, #15: CPT code 77063 is an add-on code describing screening digital tomosynthesis for mammography. Since this procedure requires performance of a screening mammography producing direct digital images (HCPCS code G0202), CPT code 77063 may be reported with HCPCS code G0202. However, CPT code 77063 should not be reported with CPT code 77067 which describes screening mammography using radiography.

ACR NOTE: There are no NCCI edits for the code pair combination 77063/77067. If your payer accepts code 77067, it may be used. The ACR argued the following in its appeal letter to CMS: “It is inherently wrong to say that 77063 can't be used with 77067. It is more correct to say that since CMS is unable to operationalize 77067, CMS instead requests that 77063 be billed with G0202 rather than 77067.”

Chapter IX-8, #18: Since the foot includes the toes and calcaneous bone, CPT code 73630 (radiologic examination, foot; complete, minimum of 3 views) includes radiologic examination of the toes and calcaneous. A physician should not report CPT code 73650 (radiologic examination; calcaneus, minimum of 2 views) or 73660 (radiologic examination; toe(s), minimum of 2 views) with CPT code 73630 for the same foot on the same date of service.

Chapter I- 24, #1: When a diagnostic procedure …For example, a physician should not report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement...) when performed in the same anatomic region on the same date of service.

Chapter IX- 22, #9: Evaluation of an anatomic region and guidance for a needle placement procedure in that anatomic region by the same radiologic modality at the same or different patient encounter(s) on the same date of service are not separately reportable. For example, a physician should not report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement...) when performed in the same anatomic region on the same date of service. Physicians should not avoid these edits by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service.

ASTRO/ACR Appeal

In response to a Jan. 18 appeal, CMS informed the ACR and the American Society for Radiation Oncology (ASTRO) that the addition of Chapter IX, F, 15: “CPT codes 77280-77290 (simulation-aided field settings) should not be reported for verification of the treatment field during a course of intensity modulated radiotherapy (IMRT) treatment” will remain, as it is CMS policy [Medicare Claims Processing Manual, Chapter 4, Section 200.3.1, rev. January 1, 2017]. The ACR will continue to work with ASTRO to address this issue with CMS.

The recent edits will remain in effect until 2018 because the NCCI Policy Manual is updated only once a year. The ACR will keep its members posted on ongoing discussions with CMS about these issues.

April 1, 2017 NCCI Edit Update - 78102/A95700, 78806/A95410

As of April 1, 2017, CMS will allow the use of NCCI-associated modifiers to bypass the edit for the uncommon circumstance where a provider performs CPT code 78102 (Bone marrow imaging; limited area) and HCPCS code A9541 (Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 mCI) on the same date of service as CPT code 78806 (Radiopharmaceutical localization of inflammatory process; whole body) and HCPCS code A9570 (Indium In-111 labeled autologous white blood cells, diagnostic, per study dose). The code pair edits will be assigned a modifier indicator of “1” on April 1.