CMS, Lab Groups Begin Talks About Issues with NCCI Edits

SERIOUS PROBLEMS WITH THE NEW GUIDELINES for the National Correct Coding Initiative (NCCI) that were  implemented on Jan. 1 have caused nine clinical laboratory associations and groups to come together and voice their concerns to the federal Centers for Medicare and Medicaid Services (CMS).

CMS implemented those changes on Jan. 1, resulting in confusion among labs about how to bill Medicare and Medicaid for certain tests. As of last month, many labs were not getting paid, lab billing experts said. The rates of denial for labs running mostly molecular tests could range from 40% to 100% of revenue, one billing expert said. (See “Nine Lab Groups Say New NCCI Policy Is Inconsistent,” TDR April 8; and “Labs Get High Denial Rates Under New NCCI Rules,” and “ACLA: NCCI Guidelines Are a ‘Step Backwards,’” TDR April 29.)

This month, however, officials from CMS and the organizations representing clinical laboratories have begun discussing how to resolve the dispute. On May 10, a spokesperson for CMS said, “We have met with several industry stakeholders regarding concerns with recent updates to the NCCI Policy Manuals and are continuing to gather additional feedback. We will continue to consider industry feedback as we evaluate these concerns.”

Lab Group Met with CMS

One group representing industry stakeholders is the American Clinical Laboratory Association. ACLA President Julie Khani confirmed that the lab group met with CMS to express concerns over the NCCI edits. “We were grateful to have the opportunity to reiterate these concerns during a recent meeting with CMS and other stakeholders,” she said. “We look forward to continuing to engage with CMS on this issue.”

In a statement to The Dark Report, the CMS spokesperson explained that CMS developed the NCCI and its policy manuals, “to promote correct coding and reduce improper coding leading to inappropriate payment of Part B claims.” The coding policies are “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.”

‘Anything but Correct’

The lab groups complained, however, that the changes CMS and the NCCI made in December appear to have had the effect of making “correct coding initiative” anything but correct, according to W. Stephen Black-Schaffer, MD, a pathologist at Massachusetts General Hospital and the Associate Chief, Education and Training, at MGH. He’s also an Associate Professor of Pathology at the Harvard Medical School.

The changes have been highly disruptive because they conflict with previous NCCI policy manual instructions and coding guidance from the AMA, the lab groups said of the changes that took effect Jan. 1. The NCCI issued the new guidelines just three weeks before they took effect and they were implemented without notice to or receiving comments from stakeholder labs.


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