AMA CPT® Assistant - 1996 Issue 7 (July)
Medicare's Correct Coding Initiative (July 1996)
July 1996 pages 1-2 Medicare's Correct Coding Initiative In response to pressure from key members of Congress, and despite significant objections from organized medicine, on January 1, 1996, the Medicare program implemented the first phase of a new "Correct Coding Initiative." The purpose of this initiative is to reduce program expenditures by detecting inappropriate coding on Medicare claims and denying payment for them. The first phase of the project involved putting into place more than 83000 code edits that were estimated to generate denials of up to 4% of claims. The GAO Report Code "edits" are designed to...
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Article Overview
This article covers the early Medicare Correct Coding Initiative, including the rationale for code editing, the role of the GAO and HCFA, and the AMA’s participation through CPT-related review committees. It is aimed at readers following Medicare coding policy, physician coding education, and the development and review of coding edits and modifiers. The piece also outlines the phases of the initiative, the types of edit categories being reviewed, and the general framework used to evaluate them.
Why This Topic Matters
It helps coding and compliance professionals understand how Medicare’s code edit program was being developed and reviewed, and why physician groups were involved in evaluating coding combinations and related policy changes.
Article Sections
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July 1996 pages 1-2
Introduces the Medicare initiative and the broader policy context surrounding the 1996 implementation period.
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The GAO Report
Summarizes the government audit background and the discussion of code editing software in Medicare and other programs.
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Phase I of the AdminaStar Project
Describes the first phase of the contractor-based code edit project and how the review process developed.
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AMA Response to Phase I
Covers the medical society response, the request for delay, and the review concerns raised about the first phase of edits.
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The Basis of the Code Edits
Explains the general sources used to develop the code edits and how they were incorporated into claims processing.
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The -GB Modifier
Discusses the introduction of a new modifier in connection with the initiative and the related CPT publication context.
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The AMA's Correct Coding Policy Committee (CCPC)
Outlines the formation and role of the AMA committee assigned to review and advise on correct coding issues.
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Questions Raised by CCPC
Summarizes the committee’s early review questions and the subjects raised with HCFA during the evaluation process.
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Phase II of AdminaStar's Contract
Describes the next review phase, the timing of specialty-society input, and the broad categories of proposed edits.
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Want More Information?
Provides a brief contact-oriented closing note related to further information on the project.
What You Will Learn
- How Medicare’s Correct Coding Initiative was introduced and organized
- What roles the GAO, HCFA, AMA, and specialty societies played in the review process
- How Medicare code edit development was being evaluated during Phase I and Phase II
- What general types of coding edit categories were under review
- How a new modifier was associated with the initiative and the CPT update cycle
Who Should Read This
- Medical coders
- Coding compliance staff
- Physician practices
- Health policy analysts
- Medicare billing professionals
Modifiers Discussed
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