ED Coding and Reimbursement Alert

Crack down on incorrect unbundling

The National Correct Coding Initiative (NCCI) has been at it again with updated edits for this quarter. NCCI volume 12.0 introduces a startling 59,080 new column 1/column 2 edits and 465 new mutually exclusive edits, and many of these code bundles could warrant a modifier 59 to optimize reimbursement.

But watch out--in a recent sampling, the U.S. Office of Inspector General (OIG) found over $59 million in overpayments to providers due to the misuse of modifier 59 (Distinct procedural service). This leaves your carrier no choice but to scrutinize your practice's NCCI savvy and modifier 59 usages like never before.

How It Works 

There are two types of NCCI edits: -column 1/column 2- and -mutually exclusive.- A column 1/column 2 NCCI edit is where one code (in column 1) comprehensively includes another code (in column 2), so you can't bill both under normal circumstances. Mutually exclusive NCCI edits are procedures that wouldn't normally be billed on the same day.

The good news: In the right cases, you may be able to override these bundles with the proper application of a modifier. Here's how:

1. Use 59 When Services Are Separate and Distinct

Modifier 59 isn't just a ticket to increase your reimbursement. Use it to -- identify procedures/services that are not normally reported together but are appropriate under the circumstances,- states the Centers for Medicare & Medicaid Services (CMS) in an article on its Web site.

These situations may include a different session or different patient encounter, a different procedure or surgery, a different site or organ system, or a separate incision/excision, not ordinarily encountered or performed on the same day by the same physician.

To read the full CMS article, visit www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf.

2. Know When NOT to Use 59

This modifier does not automatically unbundle all NCCI edits. The edits have a column that notes with a -1- or -0- whether a modifier is -allowed- or -not allowed.- You-re in the clear to unbundle the separate and distinct procedures if the edits list a -1,- but you-re out of luck if you try to do this when you see a -0.-

Next step: Don't put in modifier 59 on autopilot when you see a -1.- The edits still don't specify which modifier to use, or if a modifier even qualifies for your situation, says Denise Paige, CPC, president of the AAPC Long Beach Chapter in Long Beach, Calif. You may also have to use an anatomical modifier such as RT (Right) or LT (Left), Paige says.

Careful: RT and LT don't always pay, so check with your payers to see which modifiers they prefer for certain NCCI edits.

3. Append 59 to the Correct Code in the Bundle

If you think it doesn't matter to which code you apply the modifier, think again. The OIG has instructed CMS to -- ensure that the carriers- claims processing systems only pay claims with modifier 59 when the modifier is billed to the correct code.-

Do this: You should always put the modifier on the column 2 code, says Rick Gawenda, PT, director of physical medicine and rehabilitation at Detroit Receiving Hospital in Detroit. -If you put it on the column 1 code, you-ll only get paid for the column 1 code.-
 
4. Include Time in the Documentation

Fortunately, to justify modifier 59, good documentation doesn't mean a novel's worth of extra notes. Along with the usual documentation, the physician should record the time of day he did the procedure and use words like -after- or -followed by,- Gawenda says. Or he should mention the separate sites if it applies.

The documentation could also benefit from having the physician record diagnoses, Paige says. Diagnoses help indicate the medical necessity of the procedure(s) and justify a modifier.

Tip: If you code for a multi-specialty practice, check for patients who-ve had multiple treatments the same day--because the procedures could be bundled.

5. Audit Your Practice's 59 Usage

You may think your claims are A-OK if you-re following NCCI and Medicare guidelines, but it never hurts to see your stats. Without a self-audit, you may not realize that your facility's modifier 59 usage is above average. And these high numbers will wave a red flag at your carrier--especially after the latest OIG report.

Best bet: Keep track of how often your practice unbundles codes with modifier 59, and review the stats every quarter. If you find that you-re appending 59 a bit loosely, meet with your colleagues and discuss possible reasons for the high usage.

Remember, some practices may report 59 more often than others, such as those that perform many bilateral procedures.

Final word: Don't get confused with the different versions of NCCI edits. The NCCI usually comes out with new edits every quarter, but remember that private practices are always one NCCI version ahead of all other settings, Gawenda says. This means that hospital settings will use NCCI version 11.3 until the first of April before adhering to NCCI 12.0. Private practices should have been using NCCI 12.0 since Jan.1.