February 18, 2011
Recently, a number of members reached out to SNM regarding a sudden rejection of Medicare claims for nuclear medicine therapy and diagnostic procedures with dates of service beginning January 1, 2011. On February 17, 2011, the Centers for Medicare and Medicaid Services (CMS) officials confirmed that the recent National Correct Coding Initiative (NCCI) edit file version 17.0, submitted to Medicare administrative contractors and carriers, was incorrect with 40 code pair change errors.
The contractor that manages these files was quick in assuring the SNM that this error will be rectified with the next implementation of the NCCI edit version 17.1 on April 1, 2011. The SNM recommends that providers defer submitting Table 1 (below) code pair claims until April 1, 2011, and resubmit, reopen, or appeal any previously denied claims after April 1, 2011. The Medicare contractors will not be able to make any corrections prior to April 1st. To be clear, the contractor did implement 129 nuclear medicine code pair edits and 40 of the 129 as listed in Table 1 were incorrect. Table 2 is a listing of 89 new nuclear medicine code pair edits that will not be changed and are effective as of January 1, 2011.
Although CMS intended to add a new NCCI edit with a modifier (1) to 40 nuclear medicine therapy/diagnostic procedure code pair edits, it did not. As an example, the SNM would agree that the code pair combination CPT 78000 Thyroid uptake; single determination and CPT 79005 Radiopharmaceutical therapy, by oral administration provided on the same date-of-service (SDOS) is medically appropriate when the decision to proceed with the therapeutic nuclear medicine procedure (CPT 79005) is based on the results of the diagnostic nuclear medicine procedure (78000). Therefore, a modifier (1) would allow the two codes to be billed on the SDOS with an appropriate NCCI modifier such as modifier -59, Distinct Procedural Service, (CPT 78000-59).
Prior to January 1, 2011, and the implementation of new NCCI edits as noted in Tables 1 and 2 below, CMS did not previously require a modifier for these code pairs. For the new corrected Table 1 code pairs, claims submitted after April 1, 2011, to CMS will require an appropriate NCCI modifier on the column 2 code for claims to be appropriately paid. The newly implemented Table 2 code pair edits are remaining (0) therefore, the NCCI modifiers will not apply as these code pairs will no longer be paid when reported together on the SDOS. Instructions regarding the proper use of NCCI modifiers can be located on the CMS website Internet Only Manual, Medicare Claims Processing Manual, Publication 100-04, Chapter 23, Section 18.104.22.168.B. For more information click here.
Please refer to tables below.