Gastroenterology Coding Alert

Learn when it's OK to unbundle and increase your reimbursement potential If you-re reporting two or more distinct services, you can often legitimately override NCCI edits by applying the proper modifier. This will increase your reimbursement and the accuracy of the medical record. Must-Know Point 1: What Are NCCI Edits? National Correct Coding Initiative edits are pairs of CPT or HCPCS Level II codes that Medicare (and many private payers) will not reimburse separately except under certain circumstances. Medicare applies the edits to services billed by the same provider for the same beneficiary on the same date of service, says Kelly Dennis, MBA, CPC, ACS-AP, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla.
 
Example: The most recent edition of NCCI (version 12.1), in keeping with CPT coding principles, includes an edit pairing sigmoidoscopy (45330) with colonoscopy
with biopsy ( CPT 45380 ). This would mean the gastro-enterologist could not report 45330 and 45380 for the same patient during the same session and expect to receive reimbursement for both procedures. Point 2: What Does -Mutually Exclusive- Mean? NCCI contains two types of edits: mutually exclusive and -comprehensive/component- edits.
 
Mutually exclusive edits pair procedures or services that the physician would not reasonably perform at the same session, at the same anatomic location, on the same beneficiary, Dennis says.
 
Example: NCCI lists 44364 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor[s], polyp[s] or other lesion[s] by snare technique) as mutually exclusive of 44365 (... with removal of tumor[s], polyp[s] or other lesion[s] by hot biopsy forceps or bipolar cautery). The payer would not expect that the gastroenterologist would remove the same polyp, for instance, using both a snare and hot biopsy forceps.
 
If you were to report two mutually exclusive codes for the same patient during the same session, Medicare would reimburse only for the lesser valued of the two procedures (in the case of 44364 and 44365, the payer would reimburse only 44365). Point 3: How Do -Column 1/Column 2- Edits Differ? -Comprehensive/component- edits describe -bundled- procedures. That is, CMS considers the code listed in column 2 as the -lesser- service, which is included as a component of the more extensive column 1 procedure, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the AMA's CPT advisory panel.
 
Example: The NCCI contains an edit bundling 44380 (Ileoscopy, through stoma; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) to 44385 (Endoscopic evaluation of small intestinal [abdominal or pelvic] pouch; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). In this case, 44385 is the more extensive procedure, which includes the -lesser- procedure 44380. [...]