Last week we released part one of our two-part conversation with Christopher Chandler, a Technical Manager of Professional Documentation and Coding at Intermountain Healthcare, titled Understanding the Nuance of NPP Coding. And today we’re excited to release part two of the conversation, where we dove headfirst into the NCCI policy manual.
The NCCI policy manual has been a hot topic. And not least of which because, as Chandler put it with a grin, “people hate the NCCI Policy Manual. They see it as a big book of rules that stops them from getting paid for the stuff they are doing.”
But as you’ll hear in our conversation, the manual is so much more. Whether you need to know when you can bill two codes together, or when to use modifiers 59, 62 or 79, that’s when you should consult the NCCI manual. It’s become an indispensable resource for any compliance billing department that’s using today’s best practices.
But it’s no secret that the NCCI policy manual can be daunting, not to mention, difficult to decipher. So during the second part of our conversation with Chandler, titled, "A Deep Dive Into the NCCI Policy Manual," we pick up right where we left off to discuss the ins-and-outs of the manual, and discuss the three main topics of the manual, including:
- Knowing Exactly What’s Included in a Surgical Package
- Understanding Multiple Procedure Overlaps
- Billing Protocols for Inherent Services
CJ: Welcome everybody to another episode of Compliance Conversations, this is CJ Wolf, Healthicity's Sr. Compliance Executive. I recently had a wonderful conversation with Christopher Chandler from Intermountain Healthcare about NPP coding, and we just had to have him back. Welcome back, Christopher.
Christopher: Thank you for having me back, it’s a pleasure.
CJ: Yeah, absolutely. Today we want to talk about NCCI policy manual and kind of take a deep dive into that. I know you have a lot of expertise there. Tell us, in your opinion, why do you think that NCCI manual is important?
Christopher: You know, the NCCI manual is kind of a hot topic. I’ve given a couple of presentations about this at some conferences, and they are usually very well attended because people hate the NCCI Policy Manual. They see it as a big book of rules that just stop them from getting paid for the stuff they are doing.
Christopher: And really, it is not that way at all. It is more the instruction manual telling them why it is you can’t bill for certain things, and usually it comes down to "you can’t bill this code with this code."
CJ: Right, yeah, and now, just a little bit of background, it’s a Medicare product, correct? But a lot of payors have adopted it. Tell us a little bit about that.
Christopher: A lot of payors have adopted it, yes. So, it’s a Medicare-written manual that basically explains why they have certain edits. You may hit these Medicare edits, it doesn’t tell you why you’re hitting it, so you go to the NCCI manual to figure out why. Sometimes you can bill two codes together, other times you can’t. To find out when you can, you go to the NCCI manual, and a lot of commercial payors have adopted these same edits as well, using the NCCI policy manual as a background.
CJ: Yeah, because all of it is publicly available, right? Both the narrative portion of the manual, plus the numeric edits, it’s all publicly available, correct?
Christopher: Correct. If you were to just Google "CMS NCCI manual," it would be the first link on there.
CJ: Yeah, okay. That’s a good little bit of background. Let’s really spend our time on some of these main themes that you’ve kind of recognized. Where is a good place to start, is surgical package a good place to start?
Christopher: I think so, yeah. A lot of the NCCI manual falls down to surgical package. Meaning that when you bill a code for a procedure you are not billing for the procedure alone, you are billing for an entire package of services that usually go with that procedure. So, the CPT manual lists some of those and says, "the preoperative history and physical is not separately reportable." You always do a preoperative history and physical, so we just lumped that into this--and you’ll get reimbursed in that big lump sum--typical post-op care orders, all that is listed in the CPT manual. Then the NCCI manual comes along and says, well hold on. We’ve got four or five, maybe six more things that we want to add to the surgical package. Things like the separate procedure codes, and what about post-op complications, and anesthesia, and performing multiple procedures at the same time.
Christopher: Sometimes those overlap, and so the NCCI manual has broadened that surgical package and said because we lump all these together, and we’re considering this payment to represent all these services, there are times where you can not report two codes together because it will, if you were to report them together, the way the system is set up, you would basically be getting paid twice for something you only did once.
CJ: Yeah. I remember, and tell me if this analogy still holds true today, but years ago, when I was teaching a lot of this to doctors, I’d say, "Look, if you’re going to do a general abdominal surgery, yes, you’re going to cut open my abdomen, you’re going to do the reparative surgery, or whatever, explorative, whatever it is, and you’re just going to walk away, and leave my belly open? No, you have to close it, and there are wound codes, there are separate wound codes for closing wounds, but you don’t get to report those separate wound closures, because the work of entering my abdomen, doing some service, and closing my abdomen is all included in that one abdominal surgery code." Does that still hold true, does that thinking and rational still hold water?
Christopher: Yes, it does, it absolutely holds true. That’s what you would call an inherent service. Closing a patient, I mean it’s inherent that if you open a patient you’re going to have to close them.
Christopher: It’s included. Another inherent service are iatrogenic injuries. So when you are cutting into the patient, or this happens a lot with laparoscopic abdominal surgeries, is you’re going in and you accidentally cut into the small intestines, or poke the small intestines with a trocar when you’re doing laparoscopic surgery, so you got to repair that. So, it’s an injury that you caused, so you need to repair it, and because you caused it, you can’t bill separately for it.
Christopher: So that is another common inherent service the NCCI policy manual talks about.
CJ: Okay. Yeah, that makes a lot of sense, and the certain surgical package that you referenced, it’s more than just that day as you said. What if you have to remove the sutures six days out or something like that.
Christopher: Right, and that’s your typical post-op care, and that’s represented in both the CPT manual and then it’s harped on a lot in the NCCI manual as well because the CPT manual states that if the patient comes back and you have to do an evaluation of management service for a complication of the surgery, you should report separately. Then Medicare and the NCCI manual has said hold on, it’s common to have complications that are managed by evaluation management services.
Christopher: So, because it’s common, we consider already within the reimbursement you’re getting, so you can’t bill separate for evaluating and managing a complication of the surgery, unless you need to go back to the OR, then you can bill.
CJ: Exactly, I’m glad you brought that up, because they do draw a line. They say if it’s this kind of management, up to this level of care, it’s included, but if you have to go back to the OR then they do let you bill separately, but you probably need a modifier at that point?
Christopher: Yeah, they will let you bill separately for that procedure, but not the evaluation and management that led up to it.
Christopher: That’s where, I think, a lot of people get confused, is they say this led to the OR, so I’m billing for the E/M plus the procedure.
CJ: I see.
Christopher: That’s not allowed. You would throw on, I think it’s 79 modifier, or 78, the unplanned return modifier for the procedure, but you don’t bill separately for the E/M.
CJ: Gotcha. Yeah that’s good clarification. Good. If you feel like we’re done talking about surgical package, what’s next? Is it the multiple procedure overlap, or, what do you think?
Christopher: Yeah. That’s honestly my favorite part about the NCCI policy manual, and I sound like such a nerd when I say that, but it’s true.Because I got my start in general surgery, I still consult general surgeons, and this is something that deals with any surgeon a lot. It’s when you’re performing multiple surgeries at once, and there are multiple surgical codes for each of those surgeries. You were talking about abdominal surgeries. I’m in general surgery, so let’s stick with that. If you’re going in to do an appendectomy because the patient has appendicitis but then the inflammation has leaked and has caused corroding of the small intestines, or whatever, and you have to both dig out the appendix and remove a portion of the small intestine, there is a thing called multiple procedure overlap, where certain portions of the surgical package. If you bill for those two codes as they are, you will be saying that you did certain things twice, when really you only did it once.
Christopher: For example, the pre-op history and physical. You didn’t do a pre-operative history and physical for the partial enterectomy and the second one for the appendectomy. You just did one.
Christopher: You are not providing two sets of post-op care. You are not writing two notes. You are not using two surgical rooms.
Christopher: All these things, it’s this overlap of an area that if you were to bill it as it is, you’d be getting paid twice for something you only did once. That’s where modifier 51 comes into play.
Christopher: It helps reduce, you would add modifier 51 to the second code, saying this was a secondary procedure, and the pair will reduce the payment of the second code by the amount that is that multiple procedure overlap. Usually they say it’s about 50%.
CJ: Okay, and that makes sense, for the example you gave where you’re going in for a n appendectomy and you do some sort of other procedure on the intestines. You also didn’t open the abdomen twice, you didn’t close the abdomen twice. There are a lot of things that are worked into the work associated with a single code, like you’re saying, that you’re only doing once.
Christopher: Correct, and that’s where the 51 modifier would come into play. Depending on where you live in the country, a lot of payors will add the 51 modifier automatically. Getting in contact with the payors that you work with is essential in knowing do you put this on automatically or do you require us to do it. And that will help you because a lot of healthcare systems don’t ever put it on because they know the payor does it automatically.
CJ: Yeah, just the mere fact of them listing two abdominal surgery codes on the same claim same date of service, it’s going to be reduced by some payors.
CJ: Yeah, interesting. Anything else on the multiple procedure overlap?
Christopher: That would be it. That’s the big portion of it is it’s there to help make sure that you are accurately getting paid for the services you are providing and you’re not double dipping. And so many providers just don’t get that. They are saying, "I did this and I did that. I should bill two codes, and neither one of them should be reduced."
CJ: That’s exactly right.
Christopher: Or you see this a lot with the separate procedure codes as well. Those CPT® codes that are classified as separate procedures. Those are inherent services as well. Going back to that, you see that a lot there as well where they say,"Hey, I did two surgeries." But they don’t understand that one of those surgeries already includes that separate procedure code and reporting the code would say that you did it twice.
CJ: Is this still a separate procedure, lysis of adhesions, where you might be going in to take out the spleen or something but they have had prior abdominal surgery, so they have adhesions, so the surgeon spends a lot of time, lysis those adhesions just to get to the spleen? There is a separate code, or at least there was years ago, for lysis of adhesions. Is that the example you’re talking about?
Christopher: Yeah, it’s still there. So, lysis of adhesions is classified as a separate procedure code, and so the NCCI policy manual says, Hey, this is inclusive in every abdominal surgery." Basically, what that means is you never report a lysis of adhesion code with any other abdominal surgery code, because they already consider it part of it. Then they go on and say hey, if it’s extensive, above and beyond what a difficult lysis of adhesions would be, bill modifier 22 with the other code, and that will help. Another really good example are diagnostic types of services.
Christopher: For example, a diagnostic laparoscopy, laparotomy, so you’re just exploring the abdomen, cutting in and exploring the abdomen and trying to find out what is wrong. If you were to bill that code, with let’s say a cholecystectomy code, removing the gallbladder. Then what you’re saying is, hey I cut in and explored the abdomen twice. Once with the exploratory abdominal code, and then a second time with the gallbladder removal code, because they know you have to explore the abdomen and cut the patient open in order to remove the gallbladder, so they already have that in there. The way I try to explain that to my physicians is that they have done you favor. Instead of having to bill two, three, or four codes to represent everything you’re doing, you get to bill just one, and it’s the same amount of reimbursement it would be if you had to bill two, three, or four smaller codes.
CJ: Yeah. I often got the question from docs, well when would I ever bill an exploratory laparotomy, and the answer is if that’s the only thing you did. You open up the abdomen, you explore, you find nothing, and you close. Is that right?
Christopher: Correct. Both the CPT® manual, and the NCCI manual say that separate procedure codes should only be reported if they are completely unrelated to any other procedures being performed at the time, or they are don independently.
CJ: Yeah. The lysis of adhesions example that I gave also holds true because sometimes you can get a bowel obstruction just from adhesions and by lysing those adhesions you solve the issue. If lysis of adhesions is the only thing you did, that’s the code you report.
Christopher: That’s the code you report, if you had to go on and do something else, well, that lysis of adhesions is already, that amount of reimbursement for lysis of adhesions is already built into the other code.
CJ: Yeah, exactly. The other area where I see a lot of this is like with GI scopes, with colonoscopies and things, because there are a lot of colonoscopy codes that are different based on if you do a snare or a polypectomy, or you do something else even like diagnostic like you’re saying. You’re not sticking the scope in, taking it out, sticking the scope in taking it out, with each of these codes. You’re only inserting the scope once, you’re doing all those things, snare, polypectomy, maybe controlling bleeding, cauterization etc., so you use this multiple procedure concept, is that another example?
Christopher: That is a perfect example, the diagnostic procedure. That’s why I geek out and love the NCCI manual, because once you start understanding how the overall system is working, then the rules begin to make sense. It’s logical now, I get it. Some physicians still say well I hate it, it’s still not very fair. But they understand it. They get why it is the way it is. They may not like the system, but they understand why those rules are there.
CJ: Most of the time what I find with physicians is they are just frustrated with the overall reimbursement. They want more reimbursement.That is more of a reimbursement argument, not a coding argument, right? You don’t get more reimbursement by reporting more codes. You pursue avenues to try to increase reimbursement for the one code.
Christopher: Yes and no. Sometimes you go into these physicians' offices and you find out that they have been billing a lysis of adhesions code, or they have been billing two codes together that should not be billed together, and they have bene billing it for so long that they are used to that reimbursement amount.
Christopher: You say hey, you can’t do that, here are the guidelines, and we need to go back and fix all these past codes. And from now going forward, you can only bill this code. All of a sudden, that is a decrease. They see that as a decrease in pay.
Christopher: When really, they were getting overpaid for something.
CJ: The whole time, exactly. It’s trying to clarify that perspective a little bit, and that is hard to do when you’re talking about the work that I did, and the money I get, and that sort of thing.
Christopher: Yep. All logic seems to go out the window when you’re saying you can’t have this much money.
CJ: Exactly. So, is the third theme inherent services, we kind of touched on it a little bit, but what else on that area?
Christopher: We touched on that area a little bit, another portion of inherent services that I think the NCCI manual talks a lot about, that I really like. is going to be biopsies. They talk about when you are billing a biopsy and an excision code, if you’re biopsying a lesion then excising it later during the same surgical encounter, the biopsy is inherent to the excision. You can not bill for both. There are some exceptions, but the overall rule is if you’re biopsying a lesion and then excising that same lesion, you only bill for the excision.
CJ: Now, I’ll play the physician in a roleplay for a second. "Well okay, but what about when I excised one lesion but I biopsied three separate lesions, what do I do then?"
Christopher: That’s when you throw on a modifier to accurately reflect that these were separate sites. The 59 or the excess modifier, saying they are different. Now one of the exceptions they do have would be if you biopsy a lesion, send it to pathology immediately, and you’re waiting to hear from pathology to find out if it’s malignant. And if it’s malignant, that’s when you decide to excise the entire thing; then you can bill for both services, both the biopsy and the excision of the same lesion, because you were not intending to excise the lesion from the get-go. You were waiting to see if it was benign or malignant.
CJ: Gotcha, and then the example I used as separate lesions, your documentation needs to demonstrate that, because otherwise it will look like you did all of this on one lesion and you inappropriately unbundled.
Christopher: Yeah, you got to tell us location sites, laterality size, depth, all of it.
Christopher: A lot of documentation requirements, could have a whole episode on just that.
CJ: Yeah, exactly. That really goes along with it. One thing that I recall from the NCCI manual is the narrative text, because the manual is more or less separated in the same sections as the CPT manual. There is an integumentary chapter, a muscle, skeletal, respiratory, etc., correct?
CJ: There is a narrative portion that they use examples of codes that then you can apply that principal to other code sets.
Christopher: Correct, yes. They have the very first chapters, the general correct coding principles chapter. And that is probably the one to start with, because they go through these general ideas that we’ve been talking about today. Then you get into the especially specific chapters and you see the applications of those four specific does in that system, and specific code relationships, and things like that. For example, a very general inherent services control of bleeding. If you are providing some sort of surgery and there is bleeding and you need to control it, there is a code for control of bleeding. But if it’s during the same encounter, it’s inherent.
Christopher: However, once you get into the surgical systems, let’s say the esophagoscopy section, and you start seeing the application of it--that when you are removing a mass, or abrading a mass in the esophagus and there is bleeding--that is when you would need to control it and it is inherent of overall procedure you’re doing. But if they start bleeding two days later and you need to go control the bleeding, well, then that’s separately-reportable, because it’s a separate encounter.
Christopher: It’s really nice to be familiar with the general concepts, then you can take those concepts and find how it’s applied in those specialty specific chapters.
CJ: Yeah, and this concept of separate encounter that you just mentioned, though it’s probably rare, we can come up with some theoretical scenarios where, you know, you did something in the morning and then stabilized the patient, and it’s still the same date, calendar date, but it’s now 18 hours later, and it’s almost midnight, and you do something else. Those two codes, if they were done in the same encounter, would hit an edit and would be inappropriate to report together, but because they were done at separate times of the day, and really separate encounters, it may be appropriate to use the 59 modifier or some other modifier to designate these, even though it’s the same date. It’s truly separate. Is that true?
Christopher: Yeah, that would be a great example of using the XE modifier. The separate encounter modifier. These modifiers, the NCCI manual goes into those as well, talking about hey, the 59 modifier is good, but it’s used too liberally, so we made these four new modifiers, the X modifiers, that tell us exactly how it’s distinct. XS, it’s a distinct site, XE it’s a separate encounter, XP it’s a separate physician, or XU it’s an unusual overlap, a non-unusual overlap of services. The example you gave would be a really good example of applying what the NCCI manual is saying, is use the XE modifier instead of the 59, to be a little more specific.
CJ: Okay, and this XP is separate physician, but maybe the same group practice?
Christopher: Could be, yeah. I’ve tried to find examples of how to use the XP and any example I’ve researched or found, there is a better modifier out there. Because if it’s a separate physician, I mean, is it an assistant surgeon? Would you use the 80 modifier?
Christopher: If it a co-surgeon, would you use the 62, or a team… so, I have yet to find a really good example of when to use the XP modifier, the other three seem to be easier.
CJ: What’s the XU, is there a good example for that one?
Christopher: So that biopsy would be a great example. It’s happening in the same encounter you biopsied a lesion, sent it off for pathology, it came back malignant so then you take off the entire lesion. You would want to throw the XU modifier on the biopsy code, saying normally these overlap and normally this is multiple procedure overlap, but in this case, because it was malignant it meets the NCCI guidelines, it’s this unusual overlap. That is separately reportable.
CJ: Okay, and then the scenario I threw out, where I excised one lesion but biopsied three others separate, on those three separate biopsies, I’d use the XS?
CJ: Because they are different sites.
Christopher: And the NCCI manual even says, under the modifier 59 definition, that if there is a more accurate modifier, then, or more specific modifier, then that modifier should be used instead of 59, and I think that’s what Medicare did with this and included it in the NCCI manual saying hey, we’re making the more specific modifiers, so use these. I don’t, not all commercial payors have adopted the X modifiers, but Medicare will take both the X modifiers, or the 59 if you want to go above and beyond and be a little more specific and have perhaps less of a chance of being audited, the X modifiers might be a better way to go.
CJ: Yeah, well great. Well this is a lot of great information, we’re kind of coming to the end of our time. Do you have any last-minute thoughts or comments that you would like to share that maybe we didn’t get to talk about?
Christopher: No, I just recommend reading that first chapter. The NCCI policy manual can be your best friend or your worst enemy, depending on how well you know it. If you know it, it can help you navigate the coding system so much better, it can help reduce denials, it can help reduce the amount of edits that are happening which can help payments get out faster and speed up the billing process. It is a great tool that can be used, but it’s usually seen with this negative perspective rather than seeing it as a valuable tool.
CJ: Yeah. Great advice. Christopher, thank you so much for your time and expertise.
Christopher: You’re very welcome. Thank you for having me again.
CJ: Absolutely, and thanks to all our listeners for listening to another episode, until next time, take care.