AHA Coding Clinic® for HCPCS - 2008 Quarter 4; FOR your INFORMATION
New institutional NCCI edits to be applied to Medicare claims
Effective 1/1/09 the following categories of services: anesthesiology, evaluation and management (E/M), and mental health services, will no longer be excluded from the National Correct Coding Initiative (NCCI) edits via the Outpatient Code Editor (OCE). Accordingly, there will be a large number of new institutional edits applied to claims. Formerly, the Outpatient Code Editor (OCE) was not applied to the National Correct Coding Initiative (NCCI) edits for these services. The NCCI edits are updated quarterly and the institutional version is one calendar quarter behind the physician version. The new institutional NCCI edits will be available as of 1/1/09 on...
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Article Overview
This article covers a CMS update affecting institutional Medicare claims processing, with emphasis on National Correct Coding Initiative edit availability, timing, and the relationship between institutional and physician edit sets. It is relevant to billing staff, coders, and compliance professionals who monitor quarterly CMS edits and institutional outpatient claim processing guidance. The article also points readers to CMS resources for reviewing edit files and understanding how institutional edits may differ from physician edits.
Why This Topic Matters
The update affects how institutional claims are edited and reviewed, making it important for organizations that bill Medicare outpatient services to track CMS release timing and changes in edit scope.
Article Sections
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Effective date and service categories affected
Introduces the implementation date and the broad service categories affected by the update. It explains that institutional claim editing is changing for certain outpatient service groups.
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Background on OCE and NCCI edits
Summarizes the relationship between the Outpatient Code Editor and National Correct Coding Initiative edits. It also notes the quarterly update cycle and timing differences between institutional and physician versions.
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CMS resources for reviewing edit files
Identifies where CMS makes the relevant edit files available and notes the code families used for searching those files. This section focuses on access to the referenced official resources.
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Relationship between physician and institutional edits
Describes the connection between the physician-version edits and the institutional-version changes being added. It also notes that the institutional set may differ from the physician set.
What You Will Learn
- Which Medicare claim editing area is changing for institutional services
- How the institutional and physician versions of the edit files are related
- Where CMS directs users to review the applicable edit files
- Why institutional edits may not exactly match physician edits
Who Should Read This
- Medical coders
- Hospital outpatient billing staff
- Revenue cycle teams
- Compliance professionals
- Facility claims reviewers
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