Gastroenterology Coding Alert

Add-on codes also face these edits through bundled primary procedure. The latest version (18.3) of the Correct Coding Initiative (CCI) edits went into effect Oct. 1, 2012, with sweeping changes that prevent you from reporting skin repair codes along with almost every procedure that your gastroenterologist will perform on a day-to-day basis. Mammoth changes: "In the 15 years or so that I have been analyzing the NCCI database, this release will go down in history as the Ripley's Believe it or Not quarterly change," warns Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. "Effective October 1, 2012, there will be 233,241 new edit pairs added to the database. So, in addition to the overwhelming volume of reasons that payers use to deny payment to a practice, you can add 1 million more, which is just about the size of the new NCCI database. Over 97 percent of these were surgical procedures (codes 10000 through 69999) and almost all fell within the policy statement of 'Misuse of Column 2 code with Column 1 code.'   "Adding insult to injury, there were 474 edit pairs where the modifier indicator was changed from '1' (you may be able to bypass the policy using a modifier) to '0' (modifiers are not permitted under any circumstance)," Cohen explains. Good news:  Not all of the thousands of changes will directly impact your billing. Our experts have combed the huge database so you don't have to. Read on to learn about some of the new code pairs on which you should focus. Align With Surgical Practice Standards The culprits in all these hundreds of thousands of edit pairs are the following codes:

• 12001-12018 -- 

Simple repair of superficial wounds ...

• 12020-12021 -- 

Treatment of superficial wound dehiscence ...

• 12031-12057 -- 

Repair, intermediate, wounds ...

• 13100-13153 -- 

Repair, complex ...   "Regardless of the massive number of edits involving these codes, it shouldn't really change the way you code," says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash. "Surgical practice standards have always included the wound closure as part of a surgical procedure such as skin grafting, hernia repair, hemorrhoidectomy, etc.," Bucknam says. "These edit pairs just enforce the standards." Example 1:  The Column 1 codes do not list +43273 (Endoscopic cannulation of papilla with direct visualization of common bile duct[s] and/or pancreatic duct[s] [List separately in addition to code for primary procedure]) with these skin repair codes. Look closely, though, because not seeing +43273 on the CCI list doesn't automatically mean you can report it in conjunction with some skin repair procedures. Code +43273 is an add-on code reported with other primary ERCP procedures. The edits do apply to these primary procedures, which makes them also apply to any associated add-on codes. "It's quite common that the NCCI edits do not include all of the add-on codes since the parent codes are included in the edits," explains Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co. However, it is interesting to note that many of these procedures that are covered under these CCI edits (such as endoscopy, ERCP) do not have an accompanying skin repair procedure, in which case these edits become somewhat impertinent as it is unlikely that you would be reporting these procedures together. Example 2: None of the edits pertain to 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated). If your gastroenterologist performs any other procedure while performing 13160, report both codes on the claim. Take Advantage of Modifier Indicator '1' What if your surgeon performs a wound closure at one site and a separate surgical procedure at a different site  -- will these edit pairs keep you from capturing the pay you deserve? No:  The hundreds of thousands of CCI repair-code bundles are all marked with modifier indicator "1," which may allow you to report both the closure code and the bundled surgical procedure code. In certain clinical circumstances you can override -- not ignore -- CCI edits and receive separate payment for bundled codes. To find out if you can separately bill services, first check the "modifier indicator" in column F of the CCI spreadsheet (available online at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html). How it works:  "All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2)," explains Hammer. "Codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1, unless the edits permit the use of a modifier associated with CCI." A "0" indicator means that you cannot unbundle the two codes under any circumstances. An indicator of "1," however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate payment. Tip:  Before you override the edit, be sure you aren't falling into the misuse trap:

• Ensure that the closure code is for a procedure that takes place at a different body site or different operative session than the other surgical procedure.

 

• Append modifier 59 (

Distinct procedural service) to the closure (column 2) code when overriding the edit is appropriate.

• Remember that you will need to have documented medical necessity for both the wound closure and a separate surgical procedure.