Anesthesia Touch Points
This month we will discuss the National Correct Coding Initiative (NCCI), what it is and why it is important to providers.
The NCCI was developed by Medicare to promote national correct coding methodologies and to control improper coding leading to inappropriate payment of Part B Medicare claims.  It was originally implemented in 1996 and NCCI edits were established to prohibit payment of "bundled" services.  These edits are updated on a quarterly basis.  When a Column One code is billed with a code in the Column Two table, the Column Two code is not payable because it is considered a component part of the Column One code.  There are also Mutually Exclusive Edit tables which include code pairs that should never be reported together.  These edits sometimes allow an overriding modifier to indicate that the Column Two code was for a procedure performed on a separate anatomic location, in a separate session, or otherwise not related to the Column One procedure code.  In those cases, when the proper modifier is reported, both codes are payable.
The NCCI edits are constantly being updated and modified and these updates are published and implemented on a quarterly basis.  When Medicare originally began implementing these edits they were the only carrier using them.  Over the years more and more commercial carriers have begun to use them and now most major commercial carriers utilize them as part of their claim edits.  Medicaid began implementing them this year.
An example of an NCCI edit which applies to our anesthesia providers would be when a PA catheter/Swan Ganz is placed.  In the Mutually Exclusive NCCI edits a central line code 36556 is considered bundled with the Swan Ganz code 93503.  This is because one must establish central access which is used to thread the PA/Swan Ganz into position.  Since the central access is necessary in order to accomplish the procedure, it is not separately reimbursable.  However, on heart cases it is normally medically necessary to also establish a separate central line for fluid administration and/or monitoring purposes.  As long as the central line is separately placed and not used to float the Swan Ganz then it is separately reimbursable and we use a modifier on the claim to indicate this.  Medical necessity must be established in the medical record to justify the use of the modifier.  Modifiers cannot be used solely to bypass an NCCI edit if the clinical circumstances do not justify its use.  This is why we ask that documentation always be made in the record stating separate placement of the Swan Ganz from the central line and that medical necessity be documented for the separate central line.  Without this documentation, the carrier is free to deny the central line charge.
The NCCI manual goes into detail as to what is considered to be included in a particular procedure and not separately chargeable.  For our anesthesia providers the list of inclusive codes is quite long.  They include, but are not limited to, codes for the exam prior to anesthesia, transporting, positioning, induction of anesthesia, cardiac monitoring, pulse oximetry, ventilation management, temperature monitoring, EEG, CNS evoked responses, peripheral IV lines, placement of airway using laryngoscopy or bronchoscopy, interpretation of labs and monitoring functions, insertion of urinary bladder catheter, blood sampling, and post operative evaluation.  Nerve blocks and epidural codes are included in the edits for anesthesia.  This is why it is necessary to properly document the use of the nerve block or spinal/epidural for post operative pain control in order for it to be separately reimbursable.  Without this documentation the carrier will consider the block/spinal/epidural to be your anesthesia method or assisting your anesthesia in which case they will not pay it.  Ventilator management is only separately chargeable when done after the end of your anesthesia care.  Bronchoscopy to verify placement of double lumen airway is not separately reimbursable.  However, for most procedures utilizing one lung anesthesia (thoracoscopy, thoracotomy, anterior thoracic spine procedures) there are separate codes to charge with higher unit values when one lung anesthesia is used.  On these cases we often see physicians indicating "bronchoscopy" on the charge sheet which is not billable.  However, what needs to be documented in the record is one lung anesthesia, because this enables us to bill a higher base unit code which takes into account the additional work involved on these cases.
Invasive lines including central venous pressure lines, arterial lines, and Swan Ganz catheters are separately chargeable for the anesthesia provider but must be properly documented as to placement.  The anesthesia provider is not separately reimbursed for monitoring these lines if the surgeon or another provider places them.  That is why it is important for the anesthesiologist to document in the anesthesia record that he/she personally placed them.
Medically Unlikely Edits (MUEs) are another part of the National Correct Coding Initiative.  An MUE for a procedure code is the maximum number of units of service under most circumstances allowable for the same provider for the same beneficiary on the same date of service.  Medicare publishes some of the MUE values which they use, however some MUEs are not published by Medicare and are confidential.  An example of a MUE which applies to our anesthesia providers is for placement of central lines code 36556.  The MUE units are two (2) which means that carriers who use these tables will only allow payment for two central lines on same day by same physician.  Any more than that will be denied automatically and payment will only be considered if appeal is made with medical records justifying the medical necessity of the additional central lines.
Web site for the NCCI is located at https://www.cms.gov/NationalCorrectCodInitEd/ for anyone interested in detailed information regarding these edits.

We hope this information is helpful to you in your practice.  Check back next month for more updates.

Thank you,
Cyril Seligman
President/CEO
EMMI Physician Services, Inc.
3116 W. March Lane
Suite 200
Stockton, CA 95219
(209) 473-6555 office
(209) 473-6543 fax
(209) 607-2555 cell