A smart customer reached out with a question about what looked like a conflict - that a modifier was allowed in one setting but not another for the same two codes. While this is common (NCCI has 2 versions - Hospital and Physician), the investigation lead to a great example that illustrates an important issue with how CMS can introduce retroactive changes.

Physician NCCI

The edit for 99291 and 99283 was first published 10/1/2006. At that time, no modifier was allowed, and that logic persisted until 6/30/2008.  Here is the edit:

    Physician Version 12.3 (10/1/2006-12/31/2006)  THRU 14.1 (4/1/2008-6/30/2008)       99291  99283  HCPCS/CPT coding manual instruction / guideline 0 10/1/2006

Then, the data published by CMS at the start of the quarter for 7/1/2009, introduced a change where the modifier indicator flipped from 0 (no modifier allowed) to 1 (modifier allowed if services are separate and distinct). But the effective date was retroactive to 10/1/2006!

    Physician Version 14.2 (7/1/2008-9/30/2008) - today        99291  99283  CPT Manual and CMS coding manual instructions 1 10/1/2006

What do we do with a retroactive change like this?

Check with your payer, but this seems to imply that after CMS published this change, you should have been able to rebill any applicable 10/1/2006-6/30/2008 claims where the services were separate and distinct with a modifier to indicate this appropriately.

Hospital NCCI

Often, we'll see an edit introduced in the physician data get published to the hospital data one quarter later, but that is not what happened here.

On the hospital edits, this code pair edit first appeared in the data published 1/1/2009, and when it appeared, it had a retroactive date of 10/1/2006, with a modifier indicator of 1 (modifier allowed).  

Again, check with your payer, but that seems to imply that after CMS published this change, you should have gone back and added modifiers or changed the nature of billing for any applicable 10/1/2006-12/31/2008 claims where you were inadvertly paid for both codes without a modifier (because your scrubber would not have caught it).  The edit as published 1/1/2009 has remained unchanged since.

    Hospital APC Version 14.3 (1/1/2009-3/31/2009) - 18.1 (4/1/2012-6/30/2012)         99291  99283  CPT Manual and CMS coding manual instructions 1 10/1/2006

We've never seen guidance from CMS about what to do about these retroactive changes -- is it the provider or the payer's responsibility to adjust the claims? 

Either way, in today's intense audit environment, understanding the comprehensive history of how CMS has made changes allows for a reasonable defense that you weren't intentionally engaging in fraudulent behavior, and that you were acting on the best information available at the time the claim was submitted and paid.

How Can We Help?

It is critical that you have tools that give you the ability to dial back in time to verify NCCI and other edits. The data available on the CMS website is kept up to date, but there is no way to determine when an edit was first introduced with this kind ofpractice of introducing retroactive changes with no other notice.  If you'd like more detailed instructions on how to use our NCCI Code Pair Checking tool, please let us know!