ED Coding and Reimbursement Alert

Question: We have always added a modifier to separate National Correct Coding Initiative (NCCI) edits, but our new office manager said we need to start only using a modifier "when warranted." How do we know when the modifier is "warranted?"

Codify Subscriber

Answer: Many coders see the NCCI edits as the final word when determining which procedures can and cannot be billed together. In most cases, you'd be correct relying on NCCI edits to make sure a particular pair of CPT^® codes are appropriately billable. Perhaps the greatest misconception in all of procedural coding, however, is the belief that NCCI edits provide the end-all, be-all determination on CPT^® code combinations.

On the contrary, there's more than just an NCCI edit that needs to be taken into consideration when billing multiple surgical CPT^® codes. At the most basic level, coders are taught that, when billing two surgical procedures in the same relative anatomical location together, they check the NCCI edits. A basic NCCI check will leave you with one of three outcomes:

• No CCI edit; Before reporting code, check coding guidelines
• CCI edit. NEVER report code
• May use modifier to override CCI edit

Many coders unwittingly fall victim to the fallacy that "No CCI edit" means two (or more) codes can be unquestionably billed together. However, as the edit suggests, checking the coding guidelines is a fundamental piece of the NCCI process that is often overlooked.

The process of checking for NCCI edits sounds simple enough, but there are more factors at play here than what lies on the surface - and these considerations require more than just a basic knowledge of coding. Rather, a vast understanding of emergency department-specific anatomical concepts and »»» processes is fundamental when making final determinations on surgical code combinations. But before determining whether an NCCI edit applies to any given set of codes, you must be acutely aware of, specifically, Chapter 1 of the General Correct Coding Policies for National Correct Coding Initiative Manual for Medicare Services.

Chapter 1, Section 2 of this manual states: "Services integral to HCPCS/ CPT^® code defined procedures are included in those procedures based on the standards of medical/surgical practice. It is inappropriate to separately report services that are integral to another procedure with that procedure."

Chapter 1, Section 3 goes on to explain: "If exploration of the surgical field results in additional procedures other than the primary procedure, the additional procedures may generally be reported separately. However, a procedure designated by the CPT^® code descriptor as a 'separate procedure' is not separately reportable if performed in a region anatomically related to the other procedure(s) through the same skin incision, orifice, or surgical approach."

The NCCI manual is essentially saying that there's more at play than just NCCI edits when determining code set compatibility. Before checking NCCI edits, you should have a strong understanding of how two surgical procedures of the same anatomic location relate to one another. In fact, you should make a habit of asking yourself this particular set of questions each time you are working on two anatomically related surgeries:

• To what degree, if at all, do these procedures anatomically overlap?
• Is the work of one procedure included in the other?
• Is one procedure performed as a means of gaining access to the site of the second procedure?