Q&A: Hitting edits when reporting moderate sedation

Q: We have claims that are hitting an edit between a procedure HCPCS code and the new codes for moderate sedation (99151–99153). Since moderate sedation is no longer inherent in any procedure beginning January 1, why are these scenarios hitting an edit? 

A: Due to the changes in medical/clinical practice over the past few years, moderate sedation is no longer inherent to any procedures and is separately reportable beginning January 2017. 

The NCCI procedure-to-procedure edits indicate that moderate sedation codes 99151–99153 are still bundled into 33 surgical CPT® codes and Category III codes. These edits have a modifier indicator of 0, indicating that a modifier cannot be used to bypass the edit.

This is an error in the edit file based on the new coding structure, and according to several entities who have contacted the NCCI, it will be corrected with the April 1 edit update. According to Transmittal 3708, published February 3, the April files will be available to the MACs for loading and testing on or around February 14. Providers should watch for the updates to be posted on the NCCI website, as the corrections should be validated.

If a claim has been denied due to these errors, the claim should be brought to the MAC’s attention. Business Requirements 9970.5 and 9970.6 listed in Transmittal 3708 state:

Contractors shall not search their files to either retract payment or to retroactively pay claims. Contractors shall adjust claims if they are brought to their attention. 

CMS uses the language “shall not,” which tells the contractor they cannot search for claims that were affected by the error in the NCCI file, but must address the claim(s) if the provider brings the claim to the MAC’s attention.

CMS has not published guidance regarding any interim process until the edits are updated. Providers may want to contact their MAC regarding any interim process for these claims.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.

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