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.
 
If you were to report bundled (comprehensive/component) procedures for the same patient during the same session, Medicare would reimburse only for the higher valued of the two procedures (in the case of 44380 and 44385, the payer would reimburse only 44385).

Point 4: Can I Ever -Override- NCCI Edits?

Yes, in certain circumstances you may override NCCI edits and achieve separate reimbursement for bundled codes.
 
Step 1: Check the correct coding modifier indicator. Each NCCI code-pair edit includes a correct coding modifier indicator of 0 or 1.
 
A -0- indicator means that you may not unbundle the edit combination under any circumstances, according to NCCI guidelines. The edit bundling sigmoidoscopy with endoscopic ultrasound examination (45341) to diagnostic colonoscopy (45378), for instance, includes a -0- modifier indicator -- meaning that you may never override that particular edit.
 
An indicator of -1,- however, means that you may use a modifier to override the edit if the procedures are distinct from one another (for instance, if they occur in separate anatomic locations).
 
Example: The edit (described in -point 2- above) bundling 44364 to 44365 includes a -1- modifier indicator. This means that if the removal with snare occurs at a different location than the removal with hot forceps, you may report the services independently (note, however, that such circumstances would be rare).
 
Step 2: Append modifier 59: You must append modifier 59 (Distinct procedural service) to the column 2 code to indicate to the payer that the billed procedures are distinct and separately identifiable, says Barbara J.
Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.
 
In the example given in step 1 of a separate polyp removal at a different location, you should report 44364 (for the snare) and 44365 (for the hot forceps), with modifier 59 appended to the latter code.

Point 5: How Often Are the NCCI Edits Updated?

CMS updates the NCCI every quarter, and you should always consult the most recent version when coding.
 
The number of changes each quarter varies, but almost every update contains significant changes. -You-ll always want to be sure to be using the latest edition of NCCI,- Cobuzzi says. -If you-re one or two versions behind, you could be coding incorrectly and not even know it.-

Point 6: How can I find the NCCI edits?

You can stay up-to-date on NCCI changes two ways:
 
You can access NCCI updates through the CMS Web site www.cms.hhs.gov/physicians/cciedits/default.asp.
The CMS Web site contains a listing of the NCCI edits, by specific CPT sections, and is available free for downloading.
 
Or you may purchase a quarterly or yearly subscription to the NCCI from the National Technical Information Service (NTIS) Web site: www.ntis.gov/products/families/cci.