The Changing of the Code: Quarterly Code Changes May Require Appeal

Are your billing professionals keeping up with NCCI quarterly code changes? Now is the time to review the NCCI quarterly code change report.

The NCCI code changes went into effect July 1 and include a number of retroactive code changes that allow you to resubmit claims for additional payment. Further, the NCCI database expanded with an addition of 2,521 edit pairs and the termination of only 88 edit pairs with this quarter’s update. For the new pairs, nearly 5% of them are effective retroactively back to January 1 of this year, which means that if you were denied due to this pair prior, you have the opportunity to resubmit the claim for payment, according to an NCCI quarterly analysis published online by Frank Cohen Group.

The NCCI quarterly change report is at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Transmittals-Items/NCCI-CR7802-R2434CP.html. Further, Frank Cohen Group issues a free quarterly analysis workbook at www.frankcohengroup.com under the Library/Research and Studies page.

Once you determine the affect of the NCCI quarterly code changes on governmental payers, the more challenging task is to determine how the quarterly code change report affects commercial payer claims. Commercial payers can be selective on how Medicare code changes are implemented. Further, coding guidance is often difficult to obtain in a timely manner unless coding disclosure is addressed in the managed care contract. In the absence of clearly defined contractual wording, appeals seeking coding guidance should cite federal and state disclosure requirements which may require the disclosure of the coding rational related to benefit calculation.

However, one of the challenges in coding appeals is the form letter response. Many coding appeals are treated merely as a duplicate bill and are responded to with such form letter response as “claim paid correctly.” Due to the complexity of benefit calculations, your coding appeals should demand review of the denial by a certified coding professional.

“Providers may mistakenly think coding appeals are routinely reviewed by certified coders. Unfortunately, coding appeals are the most likely to be processed via an automated process with may not take into account claims and clinical details which a certified coder would be looking for,” said Tipton.

Consider the following appeal letter wording in appealing claims affected by the NCCI coding changes.

Dear Provider Appeals,

It is our understanding that your company has released full payment on the above referenced claim. However, it is our position that the NCCI quarterly code change report date (insert date) has addressed this edit pair and that additional benefits are due.

In order to assess the accuracy of payment, we request your response regarding how the payment was calculated and what coding edits were utilized. It is our position that any coding denial should be supported by written coding criteria which is consistently applied to all related claims.

If benefits remain denied, please provide a detailed explanation of why the charges did not qualify for the coding utilized by our billing department. Further, please furnish the name and coding credentials of the claims professional who reviewed the denial for compliance with current coding standards, including the licensing organization and any recent specialty-specific coding training received by the reviewer.

Thank you for your assistance.

Sincerely,

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