Gastroenterology Coding Alert

In certain clinical circumstances you can override -- not ignore -- Correct Coding Initiative (CCI) edits and receive separate reimbursement for bundled codes.

How it works: "All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2),"explains Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, consultant with MJH Consulting in Denver. "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."

Read on to find out when you can and cannot use modifier 59 to override the edits.

To find out if you can separately bill services your gastroenterologist performed, first check the "modifier indicator" in column F of the CCI spreadsheet. You can review the CCI spreadsheet at www.cms.gov/NationalCorrectCodInitEd.

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 overridethe edit if the clinical circumstances warrant separate reimbursement, such as a separate encounter on the same date, a separate anatomical site, or a separate indication.

Essential tip: Do not append a modifier to override a CCI bundle just to get paid or because you do not agree with a bundle. You can use a modifier to override a bundle only if your gastroenterologist's documentation supports using the modifier.

How it works: If you determine that the physician performed distinctly separate procedures, append modifier 59 (Distinct procedural service) to the code listed in column 2 of the CCI edits. Without modifier 59, the payer will simply apply the CCI edits and deny your claim. You should use modifier 59 to indicate that there were special circumstances that allow you to report the two codes together.

Watch out: CCI doesn't refer to primary procedures. It uses the terms "comprehensive" and "component." You attach modifier 59 to the component code.