Medicare Administrative Contractor WPS-GHA, which serves Part A and B Medicare providers in Jurisdictions 5 and 8, including Indiana, will soon change how they process Not Otherwise Classified (NOC) procedure codes for Part B claims. The goal, according to Mary Sue Gardner, RN/BSN, Specialist Outreach & Education, is to address the increase in Part B claims they receive with insufficient documentation and to avoid excessive denials or ADRs (additional document requests) for these claims.
What Are NOC Codes?
NOC procedure codes, which often end in 99, are included in the CPT and HCPCS code sets for use when no other procedure code definition describes the provider’s work as documented in the medical record. In fact, NOC codes will be denied if more accurate codes are found to apply during medical review.
Billing NOC Procedure Codes
According to WPS-GHA, to bill NOC procedures, not only does the code itself need to be on the claim, a detailed description must also be included with “enough information so that the reviewer can adequately determine coverage and compare the service to similar work for pricing.” Things like a detailed description of the procedure, how many instances were performed, and the body part (and number) where the procedure was performed provide the information needed. When billing for NOC drugs and biologics, the following should be included: the name of the drug/biologic, the total dosage (plus strength of dosage, if appropriate), and the method of administration.
For Part B services, the detailed description of the NOC should be included in Item 19 of the CMS 1500 claim form, or in the 2400/SV101-7 data element of the 837P electronic claim form. Because the description slot on the electronic claim form allows for only 80 characters, providers should submit additional documentation by mail, fax, or the WPS-GHA portal.
How NOC Procedures Are Currently Processed
Currently, once the NOC procedure claim is received by WPS-GHA, it’s routed for medical review. If no description is included, or if the description is inadequate, the provider is sent an ADR, and the claim will not be processed further until more detailed information is provided. If additional documentation is not sent, if the documentation added is still insufficient, or if the procedure is determined to be medically unnecessary, then the claim will be denied. At that point, providers must use the appeals process to have the claim reviewed any further.
Because of the growing number of ADRs being sent to providers for NOC procedures, however, WPS-GHA will soon be changing the process, though they haven’t said when. Under the new process, if any Part B NOC claim arrives with no or insufficient documentation, it will be rejected, or returned as unprocessable. In this case, the claim is dead, and a new claim must be submitted with appropriate documentation for the provider to be paid for the service.
In addition, WPS-GHA will be using the PWK segment in the electronic claim to help providers overcome the 80-character limit when describing their NOC procedures. In this case, the provider would include the NOC procedure code on the claim, use the 80 characters of the 2400/SV101-7 data element, and also indicate in the PWK segment how the paperwork is being submitted. Once an internal control number (ICN) is assigned to the claim, the provider can then fax or mail the additional documentation referencing that ICN.
A few things to note with the addition of the PWK segment. If nothing is included in the 2400/SV101-7 data element, the claim will automatically be returned as unprocessable, even if additional documentation is sent by fax or mail. In this case, to be paid for the service, providers will need to send a new claim with the documentation included in the appropriate slot. Also, if the PWK segment is marked, and no additional documentation is received, the claim will be denied. In this case, to get paid for the service, providers will need to use the appeals process.
For more information about billing NOC procedure codes to Part B Medicare, particularly WPS-GHA, check out the following resource: Billing and Describing Not Otherwise Classified (NOC) Codes. Also, if you aren’t already, consider signing up for WPS-GHA eNews to be notified when the change in processing NOC codes goes into effect. For more information about billing NOC procedure codes in other Medicare Jurisdictions, contact your MAC.
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