Gastroenterology Coding Alert

Learn how modifiers may help.

You may have a vague understanding of the existence of periodic National Correct Coding Initiative (NCCI) edits, but if that’s all you know, you’re missing a lot. Understanding the language and the meaning behind them can often mean the difference between an accurate and inaccurate claim.

To help you avoid coding errors and minimize rejected claims, we’ve put together this cohesive guide to walk you through the different types of edits, the logic behind them, and the ways to work around them when appropriate.

Clearly Understand What an “NCCI Edit” Means

The NCCI edits are a national standard for ensuring proper payment and coding. Or, as CMS explains it, the purpose “is to prevent improper payment when incorrect code combinations are reported” by assembling “code pairs that should not be reported together for a number of reasons” (www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/).

“The goal [in creating NCCI] was to set a methodology that would identify unbundling and over-coding scenarios,” according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Figure Out The Edit Pairs

An edit pair consist of two codes listed in two columns (bundled), known as a procedure-to-procedure (PTP) edit pair. CMS creates a PTP edit pair for two situations:

• When CMS regards a specific service (Column 2 code) as being a component part of a larger, more comprehensive service (Column 1 code).
• When CMS deems that two services (codes) would never reasonably occur together (are mutually exclusive).

If you submit a claim with two bundled codes, the Column 1 code is eligible for payment, but Medicare will deny the Column 2 code unless both codes are clinically appropriate, adequately documented, and correctly reported using coding tools such as modifiers.

Key: “When talking with your surgeons about edits, clarify that it’s not that the bundled code isn’t a paid service, it’s that it is paid as part of the primary code, so reporting the service separately is attempting to be paid for it twice,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia. “The discussion around bundling is too often that the service is being done for free, and that is incorrect.” When the second procedure is in a separate anatomical area, for example, the appropriate modifier should allow for separate payment of that additional procedure.

Understand How the Edits Work

To understand when you might legitimately override an edit pair, CMS assigns each PTP edit pair one of three modifier indicators. An indicator of 0 means that you cannot unbundle the edit pair under any circumstances, and Medicare will pay only the Column 1 code on a claim featuring both services. An indicator of 1 means that you may report both services, when medically appropriate, if you append an NCCI-associated modifier to the Column 2 code. An indicator of 9 means the edit pair has been deleted.

Example: Code 49622 (Repair of parastomal hernia, any approach (ie, open, laparoscopic, robotic), initial or recurrent, including implantation of mesh or other prosthesis, when performed; incarcerated or strangulated) is a Column 2 code to 49614 (Repair of anterior abdominal hernia(s)…) and 49615 (Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, reducible), which means they are bundled together.

Know the Associated Modifiers

NCCI-associated modifiers “allow for certain CPT^® codes to be billed together when they are medically appropriate and when the documentation supports the allowance of both CPT^® codes,” explains Johnson.

Depending on the circumstances, you can use one of the following modifiers to unbundle an edit pair:

• Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
• Global surgery modifiers: 24, 25, 57, 58, 78, 79
• Distinct service modifiers: 59, 91, XE, XS, XP, XU.

See How You Should Use NCCI-Associated Modifiers

To select the appropriate modifier, you should have an in-depth knowledge of the procedure, the anatomy, and the timing of the service relative to other procedures.

“This is especially true when it comes to the proper use of modifier 59 (Distinct procedural service),” notes Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. Modifier 59 is probably the most utilized and well-known modifier when it comes to PTP edits. “However, it’s also a widely abused modifier that some may use just to bypass an edit, so make sure you only append this modifier if it best describes the circumstances,” says Arlene Dunphy, provider outreach and education consultant at the Medicare Administrative Contractor (MAC) National Government Services (NGS).

Key: You should never use 59 as the default modifier, because it does not provide information that might align with documentation, and it does not signal to payers why the provider is unbundling the codes.

That’s why Medicare and other payers are now instructing practices to replace -59 with the X{EPSU} modifiers, which further clarify the reason for unbundling the edit pair as follows:

• XE (Separate encounter, a service that is distinct because it occurred during a separate encounter)
• XP (Separate practitioner, a service that is distinct because it was performed by a different practitioner)
• XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure)
• XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service)

Although Medicare generally encourages using an X{EPSU} modifier instead of 59, you should follow your specific payers’ instructions, but never submit both.

Medical record: Documentation is key when using modifiers to override an edit pair. The medical record must support the reason the two procedures should be unbundled and billed separately, such as “being performed on separate sites, at separate encounters, by different practitioners, or due to special circumstances, such as changing out endoscopes and then examining a different anatomic area because the two diagnostic endoscopies could not have been accomplished by a single endoscope,” explains Barbara J. Cobuzzi, MBA, CPC, COC, CPCO, CPC-P, CPC-I, CENTC, CMCS, of CRN Healthcare Solutions in Tinton Falls, New Jersey.