Question

1. Explain the modifier indicators edit

How do private payers use edits? What are the guidelines? Where are they found?

6.) Give at least two examples of edits that are screened by Medicare.

  

2. How does the medical billing specialist learn about updates and changes?

4. How can the medical billing specialist keep up with changes in payers’ rules?

Answer 1

2)There are several steps for billing professionals can take to meet industry changes head on and promote smooth billing operations and accurate reimbursements including the following:

• Review and update the order titles as applicable.

• Review and update the chargemaster.

• Monitor editing systems in place for NCCI edits.

• Educate technologists on the updates.

• Monitor denials.

• Review monthly subscriptions.

Taking these steps will greatly improve the cost-effectiveness and efficiency of billing activities, and most are relatively simple to execute with some careful effort. Because the NCCI edits are updated quarterly, keeping up with them is an ongoing process so it’s never too late or too soon for a practice to get its house in order.

for keep updated:-

• Carefully review NCCI edits, specifically changes that have been made.

• Check the wording contained in the NCCI policy manual. Wording in the manual indicates appropriate coding practices that have been found, in some cases, where an actual edit does not exist.

• Thoroughly and frequently educate staff members.

• Monitor denials from payers to identify additional possible issues, including lack of medical necessity, unbundling, incorrect code assignment, or changes that were not highlighted in the updates.

• Review auditing activity in the industry, specifically the OIG Work.

6) NCCI and MUE edits

The purpose of the NCCI Procedure-to-Procedure (PTP) edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services.

Medically Unlikely Edit

A Medically Unlikely Edit (MUE) is a US Medicare unit of service claim edit applied to Medical claims against a procedure code for medical services rendered by one provider/supplier to one patient on one day. ... MUE are designed to limit fraud and/or coding errors.Medically Unlikely Edits (MUEs) are designed to prevent incorrect or excessive coding. Units of service billed in excess of the MUE will not be paid.

Medically Unlikely Edits. Medically Unlikely Edits (MUEs) are used by the Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, to reduce the improper payment rate for Part B claims. Not all HCPCS/CPT codes have an MUE.