IS THIS PERMISSIBLE UNDER NEW JERSEY PIP REGULATIONS?
After searching various sources, we have found many people have questions when it comes to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. Do you have questions pertaining to reimbursement? Do you know what to do if problems arise? With articles written by Callagy Law’s law team, this blog will focus on many common questions and concerns surrounding legal matters which can arise in the field of healthcare law.
Let’s say someone injured their right knee in a motor vehicle accident and underwent physical therapy but still had residual pain and deficit of function. The patient went to an orthopedist, who recommended and performed a right knee arthroscopic surgery. The doctor billed two CPT arthroscopic knee surgery codes, Codes 29875 (limited synovectomy) and CPT Code 29877 (debridement/shaving of articular cartilage, or chondroplasty). The Operative Report even shows both these procedures were performed as part of the knee surgery. Why, then, did the PIP insurer only reimburse the doctor for treatment under CPT Code 29875? Isn’t the doctor entitled to Separate Reimbursement for the procedures performed under CPT Code 29877? The short answer is no, as discussed below.
More specifically, the governing PIP regulation, N.J.A.C. 11:3-29.4 (g)(1) states:
Artificially separating or partitioning what is inherently one total procedure into subparts that are integral to the whole for the purpose of increasing medical fees is prohibited. Such practice is commonly referred to as “unbundling” or “fragmented” billing. Providers and payors shall use the National Correct Coding Initiative (NCCI) Edits, incorporated herein by reference, as updated quarterly by CMS and available at http://www.cms.hhs.gov/NationalCorrectCodInitEd/. Modifier 59 and other NCCI-associated modifiers should not be used to bypass an NCCI edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used. For more information on the criteria for the use of modifiers, see the NCCI Policy Manual and Modifier 59 Article referenced in (g) above.
Therefore, to determine if a medical provider is entitled to separate reimbursement for multiple CPT Codes, the NCCI Edits must be reviewed. Information on NCCI Edits may be found at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.
A pair of codes must be looked up to determine if there is an NCCI edit. If the codes do appear on the list of NCCI edits, check if the edit was in effect the date the treatment was performed. There is a column for “effective date,” as well as “deletion date.”
Let’s assume your pair of codes are on the NCCI edit list and the edit was in effect when the treatment was provided. The next issue is whether the edit is designated a “0”, a “1” or a “9.” If your pair has a “9” designation, there is no conflict. If your pair has a “0” designation, you are not entitled to separate reimbursement for both codes. If, however, your pair has a “1” designation, you may be entitled to separate reimbursement if the conditions for separate reimbursement are met. The conditions are billing with a proper modifier (often a -59 modifier) and having the proper documentation to support separate reimbursement. The type of documentation generally required for separate reimbursement is proof the second treatment was “over and above” or “separate and distinct” from the treatment provided under the first code.
In our example above, CPT Code 29877 is not separately reimbursable from CPT Code 29875. The NCCI edit conflict is set forth below, and contains a designation of “0,” meaning no modifier and documentation will overcome the bundled designation of the second code.
|Column 1||Column 2||* = In existence prior to 1996||Effective Date||Deletion Date
An example of a “1” designation is billing for an arthroscopic shoulder surgery under CPT Code 29827 (rotator cuff repair) and 29825 (lysis and resection of adhesions). The pair of these codes has a “1” designation. Use of a -59 modifier with adequate documentation justifying the second code may result in separate reimbursement.
It is important to be familiar with current NCCI Edit conflicts and requirements to obtain separate reimbursement, when applicable.
We hope you found the information provided in this article helpful to various questions you may have had concerning the healthcare industry. For information pertaining to our services for medical providers, please click here. Please note, Callagy Law has recovered over $175,000,000 for medical providers, and that number grows daily. Please free to reach out to Sean Callagy of Callagy Law at any time for questions you may have concerning personal and business matters. Callagy Law offices are located conveniently in Paramus, NJ. Beyond the scope of information, Sean Callagy has developed multiple areas of our healthcare legal practice and business coaching. Feel free to connect with us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.
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