Medicare Billing Edits: A Guide to Regulations, Research, and Resolutions

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Medicare Billing Edits: A Guide to Regulations, Research, and Resolutions

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Available October 2017

Medicare Billing Edits: A Guide to Regulations, Research, and Resolutions

Denise Williams, RN, COC 
Valerie Rinkle, MPA

Available October 2017

Claims returned with National Correct Coding Initiative (NCCI) edits or Medically Unlikely Edits (MUE) can easily be lost in the shuffle. It's often not clear who is responsible for resolving an edit, and delays from other departments can hold up the process. Some hospitals may even write these claims off, leaving money on the table.

Resolving edits can be overwhelming, causing staff to work the same edits repeatedly, unless time and resources are spent to identify and fix the root cause of the problem. Medicare Billing Edits: A Guide to Regulations, Research, and Resolutions will help readers understand Medicare claims edits and give them practical tools and information to efficiently handle these edits, helping to ensure compliance and protect revenue. This robust offering includes a book, webinar, FAQs, and downloadable resources that help break down the definition, resolution, and tracking of NCCI edits and MUEs.

Nationally recognized experts Valerie Rinkle, MPA, and Denise Williams, RN, COC, leverage their years of experience as they cover the details of common edits. Using case studies and scenarios, this book will also walk readers through the edit process and show them how to apply the information they’ve learned.

This book takes readers through Medicare edits from beginning to end and includes: 

  • Downloadable tools and forms to put knowledge to practical use 
  • Answers to commonly asked questions 
  • Tips for handling the most common edits 
  • Setting-specific guidance on how to correctly resolve edits 
  • The on-demand version of the “NCCIs and MUEs: Solving Claims Edits” webinar to train a team or allow readers to learn at their own pace


Downloadable Tools:

  • A list of drug MUEs and MAIs with the OPPS status indicator to highlight packaged vs. separately payable drugs 
  • A list of non-drug MUEs that apply to unconditionally packaged services (status indicator N) 
  • Example of rate setting and how adjusting charges off versus correcting coding and leaving charges impacts rate setting 
  • Best-practice model for applying edits internally, researching and resolving edits, and why this is the recommended place in the process; strategies for working with a clearinghouse vendor who doesn’t want to release a claim because an MUE hasn’t been resolved 
  • Content from the “NCCIs and MUEs: Solving Claims Edits” webinar 
  • NCCI and MUE FAQ 


About the Authors:

Valerie Rinkle, MPA, is a lead regulatory specialist and instructor for HCPro's Revenue Integrity and Chargemaster Boot Camp®, as well as an instructor for HCPro’s Medicare Boot Camp®—Hospital Version and Medicare Boot Camp®—Utilization Review Version. Rinkle is a former hospital revenue cycle director and has over 30 years in the healthcare industry, including over 12 years of consulting experience in which she has spoken and advised on effective operational solutions for compliance with Medicare coverage, payment, and coding regulations.

Denise Williams, RN, COC, is senior vice president of the revenue integrity division and compliance auditor at Revant Solutions in Ft. Lauderdale, Florida. She has more than 30 years of healthcare experience, including a background in multiple areas of nursing. For the past 20 years, Williams has been in the field of coding and reimbursement and has performed numerous E&M, OP surgical, ED, and observation coding chart reviews from the documentation, compliance, and reimbursement perspectives. She serves as a contributing author to articles published in HCPro’s Briefings on APCs and is a nationally recognized speaker on various coding and reimbursement topics. 


Page count: 100 
Dimensions: 7 X 9 
ISBN: 978-1-68308-593-5 

Table of Contents:

Introduction to Medicare Claims Edits

Background/History of Edits
Rationale for Edits
Physician and Provider Edits
Annual Policy Manual
Quarterly Edit Files

Part I – Edits and Best Practices for Edit Management

Chapter 1: Types of NCCI Edits

Procedure-to-procedure (PTP)
Add-on
Medically Unlikely Edits (MUE)

Chapter 2: Resolving Edits

Correct coding principles
AMA CPT vs. CMS guidance
Modifiers
Charge structure reporting considerations

Chapter 3: Best Practices for Edit Management

Application of edits to accounts based on payer (what)
Process application for edits (when)
Research and final resolution of edits (who)
Claim denials due to edits
Advocating for changes to edits

Part II – Examples and Application of Best Practice Edit Management Principles

Chapter 4: Procedure-to-procedure (PTP) edit examples

Chapter 5: Add-on code examples

Chapter 6: Medically Unlikely Edit (MUE) examples