The "Black Box" of ACR Advocacy and Economics: The National Correct Coding Initiative

From the Chair of the Commission on Economics

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Thank you, Connie Lu, MD, for last month’s fantastic article about the National Correct Coding Initiative (NCCI). While coders are well-versed in NCCI, most radiologists have little understanding of the importance of NCCI Procedure-to-Procedure (PTP), Medically Unlikely Edits (MUE) and Add-on Code (AOC) edits. Why is it that we don’t hear more about these edits, and specifically, what is the ACR doing about them on our behalf?

The NCCI process is bound by confidentiality rules that prohibit discussion of any “proposed edits,” though we can publicly discuss enacted edits. Few radiologists know that the NCCI publishes lists of proposed upcoming PTP, MUE and AOC edits at least quarterly. These lists are typically thousands of rows long and must be sorted through in painstaking detail, line by line, to determine which proposals may have an adverse impact on radiology.

ACR staff make the first cut at reviewing these extensive lists by going through every line and highlighting any proposed edits that involve procedures that diagnostic radiologists, interventional radiologists, radiation oncologists, nuclear medicine physicians or medical physicists might use. This critical first pass by multiple dedicated ACR staff members gets these extensive lists down to a workable volume of hundreds of proposed edits for our ACR economics physician volunteers to then go through to evaluate for potential impact on our specialty. Through many hours of individual review followed by extensive email and virtual discussions with staff collaboration, our team determines which proposed edits we need to argue against and outlines compelling clinical detail for why an edit is improper or detrimental to the care of our patients.

 

Once we have determined which edits should NOT be implemented, we then need to convince CMS (which owns NCCI) of our point of view and explain WHY they should not be implemented. This requires drafting a letter to NCCI and often involves collaborating with other specialty societies, all of which is executed by ACR staff. After multiple rounds of editing by volunteers, the letter is submitted by ACR staff to NCCI. Almost every quarter, we spend hundreds of hours of staff time to produce such letters arguing against one or more proposed PTP, MUE and AOC edits.

Through ACR staff diligence and expertise, we can recognize and preemptively appeal any proposed damaging edits. We are fortunate to have a high rate of acceptance of our letters, which results in the proposed edits not being implemented. Inevitably, the NCCI sometimes disagrees and notifies us that they still intend to implement the proposed edits. In these situations, staff often interact directly with NCCI staff to set up meetings so physician volunteers can explain in person and in greater detail why the proposed edits don’t make clinical sense and may harm patients. We can further avert many more through this process. But, when we are unsuccessful, the edits come to pass and get enacted, though we still have the remaining opportunity to argue for repeal.

For better or worse, almost all of this process is bound by strict confidentiality. We are not allowed to inform members of any proposed edits, nor of specific staff and volunteer efforts to argue against them. The only time we will inform members and tout our success is in those few cases where we succeed in reversing an enacted edit. Since enacted edits are public knowledge, we are allowed to inform our members of those wins. However, our members never see the vast majority of this process because we typically successfully avert almost all harmful edits during the confidential proposal period, rather than having to appeal an edit after it has been enacted. Therefore, radiologists never hear about all the edits that “could have happened,” many of which could be devastating to our practices and for the patients we serve.

YOUR ACR Association® (ACRA®) member dues go primarily to fund advocacy and economics efforts, as the funds generated by other revenue streams of the College (accreditation, registries, CME courses, etc.) do not fund these critical activities. When folks ask where their member dues are going, their dues fund a world-class economics staff that protects us from unreasonable NCCI edits. That is just one of many invaluable advocacy and economics member benefits.