![]() ![]() CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. ![]() National Correct Coding Initiative (NCCI) Hospital Version The AMA defines a new patient as "one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years." Given this definition, if a physician bills a new patient visit, and the same physician or a physician from the same group practice with the same specialty has performed any other evaluation and management code in the previous three years, then the second new patient visit will be denied. Payment is not made for a procedure code that has a status indicator of "N", meaning that per the Medicare Physician Fee Schedule these procedures are not covered by Medicare. The global surgery concept applies only to primary surgeons and co-surgeons. The global surgery period applies only to surgical procedures that have postoperative periods of zero, 10 and 90 days. Global surgery includes all necessary services normally furnished by the surgeon before, during and after the surgical procedure. Payment is not made for claims that contain an invalid primary diagnosis code, based on coding guidelines outlined in the Official ICD-9-CM Guidelines for Coding and Reporting. Medicare uses another code for reporting of, and payment for, these services. Payment is not made for a procedure code that has a status indicator of "I", meaning that per the Medicare Physician Fee Schedule these procedures are not valid for Medicare purposes. A procedure code that has a status indicator of "P" or "B", meaning that per the Medicare Physician Fee Schedule this item or service is incidental or bundled in to another service and will not be separately payable. There are a number of services and supplies whose payment is bundled into the payment for other related services. Similarly, certain diagnosis codes are age- or gender specific as well. ![]() Unless a more restrictive Wellcare Clinical Coverage Determination exists, Wellcare relies on guidance published in Local Coverage Determinations, respective to the state in which the service is rendered, to determine coverage requirements.Ĭertain procedure codes, by definition or nature of the procedure, are limited to the treatment of a specific age or age group or gender. ![]()
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