Denied Claims Set for Reprocessing

The NCCI edits effective July 1, 2013, which bundled most exams with minor and major surgical procedures, have caused numerous claim denials.  Many Medicare contractors published an acknowledgment of the problem on their websites that read as follows. 

“Changes to the July 2013 NCCI edits for Evaluation and Management (E/M) codes, including Eye Examination codes 92012 and 92014 submitted with Current Procedural Terminology (CPT) modifiers 25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or 57 (decision for surgery) are resulting in claim denials when billed on the same day as a procedure or service included in the NCCI edits.” 

As we previously reported, these edits will be suspended on October 1, 2013.  Many questioned what would happen with previously denied claims.  ASCRS reported last week, “CMS alerted providers this week that it was correcting inappropriately denied claims for codes 92012 and 92014 with the modifiers 24, 25, and 57. The denied claims will be automatically reprocessed, and providers do not need to take any additional action.”  Note that this is a suspension; the edits are not being rescinded.  Once the Medicare contractors and CMS work out the programming issues, we expect the edits to be reinstated.

At this time, we recommend closely monitoring denied claims to ensure that they are reprocessed without any action on your part. 

This is also a good opportunity to review the proper use and documentation requirements for modifier 25.  The NCCI edits were implemented because CMS believes that many of these claims are being billed and paid in error.