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RPA Comments on NCCI Edits Affecting Dialysis and Evaluation and Management Services

Creation/Revision Date: August 04, 2014

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August 4, 2014 

Niles R. Rosen, MD 
Linda S. Dietz, RHIA, CCS, CCS-P 
National Correct Coding Initiative 
Medically Unlikely Edits 
Correct Coding Solutions, LLC 
P.O. Box 907 
Carmel, IN 46082-0907 

Dear Dr. Rosen and Ms. Dietz, 

The Renal Physicians Association (RPA) is the professional organization of nephrologists whose goals are to ensure optimal care under the highest standards of medical practice for patients with renal disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with renal disease. We appreciate the opportunity to provide input on NCCI edits affecting dialysis care. 

RPA is writing to follow up on our recommendation from June 2013 (appended to this correspondence) that NCCI in collaboration with the Centers for Medicare and Medicaid Services (CMS) rescind the NCCI coding edit affecting the outpatient dialysis coding family (CPT codes 90951-90970). The edit pairs the dialysis service codes as column 1 codes with column 2 CPT codes 99221-99223 and 99231-99233 describing initial and subsequent inpatient hospital services. We now urge NCCI and CMS to permanently rescind the edit. 

Briefly, our letter from June 2013 expressed complete support for NCCI’s and CMS’ efforts to eliminate duplicative, inappropriate, and/or illogical combinations of professional services in the Medicare Fee Schedule. However, RPA noted that because this specific edit both commingled inpatient and outpatient services provided by dialysis patients, and did not account for the timing issues associated with billing individual by-day services and a monthly capitated service, it was in our opinion unnecessary, confusing and administratively burdensome. 

NCCI’s response to RPA from July 2013 stated that the edit was being suspended until January 2015 and recommended that RPA undertake an educational effort with its members on the use of modifier 25 if appropriate when billing for inpatient E&M services in the same month as outpatient monthly capitated dialysis services. RPA fully agrees with the use of such educational efforts in general, as in the past we have developed a full suite of educational modules when the Medicare kidney disease education (KDE) benefit was implemented in January 2010, and pursued extensive educational efforts with our membership when the physician-patient face-to-face visit requirement for home dialysis MCP services was established in 2011. 

However, in this particular situation, we do not believe an educational effort will resolve the concerns created by the edit, especially with regard to the timing issue. As noted in the 2013 correspondence, since the monthly ESRD codes represent capitated services that capture all of the outpatient care provided to ESRD patients over a month’s time, those services are typically billed after (but near) the beginning of the subsequent month (i.e., the claim for MCP services rendered in July is billed during the first week of August). However, coding convention indicates that the inpatient E&M services rendered to the same patient (the column 2 codes in this case) are typically billed as soon as practicably possible after the services are rendered. Following our example, a column 2 inpatient hospital visit represented by CPT code 99221 with a date of service of, say, June 5, would be billed several weeks prior to the column 1 MCP service, and thus the column 2 service would be processed for payment and the column 1 service would be rejected. The RPA office received a multitude of calls from nephrology practices in the first half of 2013 indicating that this has occurred with their inpatient E&M and MCP services, requiring appeals and re-billing of services. Given the fact that inpatient E&M services can only occur in the inpatient setting and the MCP services can only occur in the outpatient setting, we believe that the requirement for the modifier is redundant and onerous. 

Accordingly, we believe that this specific coding edit would create more problems for Medicare Administrative Contractors (MACs) and nephrology practices nationwide than it would resolve, leading us as noted to urge NCCI and CMS to permanently rescind this edit. 

RPA welcomes the opportunity to work collaboratively with NCCI and CMS in their efforts to improve the quality of care provided to the nation’s kidney patients, and we stand ready as a resource to NCCI and CMS in future endeavors. Any questions or comments regarding this correspondence should be directed to RPA’s Director of Public Policy, Rob Blaser, at 301-468-3515, or by email at

Thank you, 
Rebecca Schmidt DO signature
Rebecca Schmidt, DO 

Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

Phone: 301-468-3515
Fax: 301-468-3511

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