Georgia's Trusted Healthcare
& Medical Provider Attorneys

Archives for December 2012

Happy Holidays from Jeyaram & Associates

HappyHolidaysWishing you and your loved ones peace, health, happiness and prosperity in the coming New Year.

Jeyaram & Associates’ “white elephant” office party at Pure restaurant caught the attention of Santa!

Latest Legal Healthcare News in Jeyaram & Associates Newsletter

Jeyaram & AssociatesDid you receive the latest edition of the Jeyaram & Associates newsletter this week? If not, click here.

The newsletter includes information about:

    • A new healthcare law that goes into effect January 1, 2013 – make sure you’re ready!
    • How to deal with Medicaid’s adoption of the NCCI edits

And more…

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Another Reason for Denials: Medicaid’s Adoption of NCCI Edits

DCH Denies Medicaid Provider ClaimsEffective September 27, 2012, the Georgia Department of Community Health (DCH) adopted the National Correct Coding Initiative (NCCI) for all Medicaid providers.

For many providers the use of the edits will come as a shock and result in many more denied claims.

Basically, the NCCI takes HCPCS and CPT codes that are usually not billed together and the second code is automatically denied payment. These incompatible codes are called “Medically Unlikely Edits” (MUE).

But what if the second code is medically necessary?  This is where DCH and Medicare differ in one critical way that will effect all providers!

Under Medicare, a provider would bill a clinically appropriate modifier and the claim would usually pay. DCH requires providers to appeal the MUE denial on a Form 520A and submit supporting clinical information.

DCH’s NCCI announcement says that modifiers will be accepted but feed-back from the Department says that modifiers are not accepted and denied codes must be appealed. The result for providers is more paperwork!

It is our opinion that DCH is required by the federal government to accept the modifier codes.

Make sure you preserve your appeal rights by submitting all appeal paperwork by the deadline. Hopefully, DCH will accept modifiers or its unwillingness to do so will be challenged on appeal.

For help appealing claims denials or other healthcare regulatory needs please contact DJ Jeyaram at