The following scenarios are designed to help providers with the following billing situations:

• When an outpatient facility and surgeon bill separately for supplies
• When modifiers LT and RT have been inappropriately billed on the same claim line
• When submitting an appeal for a claim denied or cut back due to a National Correct Coding Initiative (NCCI) claims processing edit

Situation One: Surgery is performed in an outpatient facility. The facility submits a claim for room use and supplies. The surgeon submits a claim for the procedure itself. One of the providers receives Remittance Advice Details (RAD) code 9941 or void 525 due to National Correct Coding Initiative (NCCI) edits in the Medi-Cal claims processing system.

Note:

RAD code 9941 descriptor is NCCI column 2 procedure code is not allowed when column 1 procedure has been paid.

Problem: The surgeon and the facility entered different procedure codes on their claims when they should have used the same procedure code with differentiating modifiers. In these cases the service codes reflect the same service but different levels of complexity. As a result, NCCI-related edits (column 1/column 2 edits) in the claims processing system judged the two procedures mutually exclusive.

Fix: Both providers should have used the same service code and let the unique modifier(s) appropriate to their provider type allow the claim to pay correctly. In addition, the supply billing should include NCCI-associated modifier 59 (distinct procedural service) on the claim line. Modifier 59 will clarify that the procedures billed are not duplicate procedures.

Modifier 59 must be entered on the claim line after other required modifiers, such as UA (surgical or non-general anesthesia related supplies and drugs) or UB (surgical or general anesthesia related supplies and drugs).

Providers may elect to appeal denials or voids that have resulted to date. The appeal should reflect the correction or addition of the modifier.

Situation Two: A provider submitted a claim with modifiers LT and RT on the same claim line. The provider received RAD code 9940.

Note:

RAD code 9940 descriptor is NCCI quantity billed is greater than the allowed MUE (Medically Unlikely Edit) quantity.

Problem: The claims processing system disallows modifiers LT and RT on the same claim line.

Fix: If the claim is within billing time limits, resubmit the claim with modifiers on separate claim lines. If the claim is beyond the six month billing limit, the provider should submit an appeal. (See next item.)

Situation Three: A provider submitted an appeal after receiving RAD code 9941 or void 525. The appeal was denied because it lacked sufficient information for the claim to be paid. Providers are reminded that for an appeal to result in a different adjudication decision, additional documentation and/or corrections are required. Appeals submitted lacking these actions will result in denial.

Fix: In general, claims denied due to RAD code 9941 or void 525 may be corrected by submitting an appeal that includes the correct procedure code and modifiers, including NCCI-associated modifiers as needed to clarify situations that the claims processing system may see as already paid by another claim or medically unnecessary.

Note:

NCCI edits were incorporated into the Medi-Cal claims processing system effective March 28, 2011. Efforts were made to anticipate discrepancies between established Medi-Cal edits and NCCI edits but it was understood some differences would be identified only as claims were processed. The Centers for Medicare & Medicaid Services (CMS) website is the official location for NCCI information.