ED Coding and Reimbursement Alert

Review these tips to fully understand how CCI impacts your code selection.

Write a simple catchy lead sentence that summarizes the challenge with CCI for ED coders. Make this really ED-focused.

What's CCI? National Correct Coding Initiative (CCI) policies were established by The Centers for Medicare and Medicaid Services (CMS) based on coding conventions that are defined in the AMA's CPT® manual, local and national policies and edits, guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.

What're edits for? Edits were developed to prevent incorrect coding, which in turn could lead to improper payments for services. These edits are utilized by Medicare claims processing contractors to review claims for physician services and outpatient hospital service. The National Correct Coding Initiative Manual for Medicare Services is updated annually in October and is a reference to explain the rationale for the code edits. However, the CCI edits are updated quarterly.

Providers and coders should be aware that the CCI does not include all possible combinations of correct coding edits, says Sarah Todt, RN, CPC, CPMA, CEDC, Director of Quality & Education for LogixHealth in Bedford, MA. Additionally, these edits do not supersede any other CMS national coding, coverage or payment policy.

There are two global classifications of edit sets: CCI code pair edits (Column 1/Column 2 and Mutually Exclusive Codes) and Medically Unlikely Edits (MUE), Todt explains. Both sets of edits are further delineated into: 1) physician or practitioner edits and 2) facility outpatient edits. The outpatient facility edits are found in the Outpatient Code Editor (OCE). CCI edits are incorporated into the OCE and typically appear one calendar quarter behind the CCI. The edit tables are updated quarterly and published on the CMS website. These types of edits evaluate codes that are submitted for the specific day of service by a single provider, she adds

Code pair edits consist of two different types. The first type, Column 1/Column 2 codes, evaluate for incorrect reporting of two codes that should not be reported together.

ED coding example: A patient sustained an injury to the finger nail after a rock fell on to his right index finger. The procedure documented included removal of the nail (11730, Avulsion of nail plate, partial or complete, simple; single) and repair of the nail bed (11760, Repair of nail bed). 11760 is considered a column 1 code to 11730. This code pair triggers a CCI column 1/column 2 edit. Of note, there are also sub-modifiers within the CCI edits. The sub modifiers are defined as follows:

• Modifier 0 indicates that there are no circumstances in which a modifier would be appropriate. The services represented by the code combination will not be paid separately.
• Modifier 1 indicates that a modifier is allowed in order to differentiate between the services provided. Assuming the modifier is used correctly and appropriately, this specificity provides the basis upon which separate payment for the services billed may be considered justifiable.

Don't miss: 11730 is listed with a sub-modifier of 1 so it is eligible for a CPT® modifier to override the CCO edit.

If documentation shows that the two procedures were performed on separate anatomic locations, both procedures may be reported with the appropriate modifier (typically a 59 modifier). In the example above, the procedure was performed on the same anatomic location, so the nail avulsion would be considered a component of the nail bed repair and should not be reported separately, Todt explains.

MECS and MUEs edits also impact code assignments

Be on the lookout for Mutually Exclusive Codes (MEC) pair edits which indicate incorrect reporting of two services that are unlikely to occur together. These edits take into consideration procedures that cannot be reasonably performed on the same anatomic site or during the same encounter.

For example, MEC edits would include such services as reporting code 36556 (Insertion of non-tunneled centrally inserted central venous catheter, age five years or older) in addition to reporting a 36568 (Insertion of peripherally inserted central venous catheter [PICC], without subcutaneous port or pump; age 5 or older) during the same encounter.

Units matter: Medically Unlikely Edits (MUE) indicate an improper number of units reported for a particular procedure. For example, reporting 3 units of 25605 (Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation).

Given the fact that a patient has only two arms, it is medically unlikely that three procedures would be reported.

Adding a Modifier? Tread Cautiously

Modifiers provide additional information regarding the circumstances involving a particular procedure. The reporting of multiple procedures often requires the use of modifiers. However, modifiers should only be applied when the appropriate conditions are met. If a provider submits a code pair in which an edit occurs without a proper modifier, only the Column 1 code will be paid and the Column 2 code will be denied -- and your reimbursement will take a hit.

Conversely, if an appropriate modifier is applied to the code pair and both codes are clinically appropriate, then the edit will be bypassed, which keeps the money flowing for your services.

Vital: Documentation must clearly support the use of the modifier to bypass the edit as with the finger injury above. In particular, the 59 modifier is a frequent audit target item and is included in the Office of the Inspector General work plan, so be sure that any modifier employed to bypass an edit is done compliantly with the proper clinical circumstances and documentation in place as to why it was a distinct service; such as a different site or area of injury.

Watch the Edit Indicator for Direction

As mentioned above, edit details will include information regarding modifiers for the code pair. The indicators, which appear in a footnote-type superscript format in the code pair tables, will be either: 0, 1 or 9.

The indicator will inform you whether a modifier will cause the code pair to bypass the edit. The indicator of "0" specifies that a modifier is not allowed and will not bypass the edit; an indicator of "1" specifies that modifiers are allowed when appropriate and will bypass the edit.

Additionally, the indicator of "9" is for code pairs that have been deleted and is used so there are no blanks in the table.

Coders must determine if one of the codes should be omitted or if modifier application is appropriate when an edit is identified, Todt instructs. Reporting both codes together without modifiers will generally result in payment denial for one of the services. Code pairs submitted with identical modifiers will be subject to CCI edits.

The 59 modifier is the most frequently used modifier to bypass a CCI edit. Although this modifier will allow a procedure to bypass an edit, you should not automatically apply it in every instance when a modifier is allowed. (For more information from CMS on how to use modifier 59, see https://www.cms.gov/nationalcorrectcodinited/downloads/modifier59.pdf.)

ED coding example: A patient is seen with injuries after a fall. The patient suffered a head laceration and a sprained wrist. The scalp is sutured in a single layer (12001, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) and a splint is applied to the wrist (29125, Application of short arm splint [forearm to hand); static.) This code pair has an edit but does allow a modifier. For this service a 59 modifier may be applied to the laceration repair to indicate a separate anatomical location.

Modifier 59 should only be used if no other modifier that more appropriately describes the circumstance is available. The primary purpose of this modifier is to indicate different anatomic sites of different procedure or surgery. The edit indicates the two procedures cannot be reported if performed at the same anatomical site. Procedures performed on contiguous structures of the same area are not considered different anatomic sites. For example, if the ED physician treats an injury to the same digit involving a nail avulsion, the nail bed repair and repair of adjacent soft tissue would under most circumstances constitute a single anatomic site, Todt explains.

Resource: NCCI Policy Manual/ How to Use The National Correct Coding Initiative (NCCI) Tools https://www.cms.gov/nationalcorrectcodinited