Gastroenterology Coding Alert

Tired of bungling bundles and misinterpreting mutually exclusives? Brush up on your National Correct Coding Initiative (NCCI) terminology and avoid mistakes that could otherwise put you in the NCCI doghouse.
 
Mutually exclusive codes. According to NCCI, mutually exclusive codes are those that should not be billed together due to conflicting CPT definitions or the medical impossibility/improbability that the procedures could be performed at the same session. When you report codes NCCI identifies as mutually exclusive for a single treatment session, the carrier will usually recognize and reimburse only the lesser-valued procedure.
 
For example, if a gastroenterologist performs an endoscopy (44360, Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), she would not also code for 43313 (Esophagoplasty for congenital defect [plastic repair or reconstruction], thoracic approach; without repair or congenital tracheoesophageal fistula) during that session because it would be medically improbable to perform both of these services during the same treatment session.
 
Bundled codes. A bundle describes a pair of codes, one of which represents the comprehensive code and the other the component code.
 
NCCI considers the service represented in the component code included in and not separately billable from the service represented by the comprehensive code. NCCI outlines the rationale for bundling component codes into comprehensive codes:
 
 The included (or bundled) service represents the standard of care in performing the overall service (the comprehensive code)
 
 The included service is necessary to successfully accomplish the comprehensive procedure; failure to perform the component procedure may compromise the success of the procedure
 
 The component code does not represent a separately identifiable procedure unrelated to the service represented by the comprehensive code.
 
For example, if your gastroenterologist is providing a colonoscopy with dilation by balloon (45386, Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures), you would not separately bill 45910 (Dilation of rectal stricture [separate procedure] under anesthesia other than local). NCCI considers 45910 a component of the comprehensive code, 45386, and therefore not separately chargeable.
 
Remember: If a bundled component code has a status indicator 0, you can never use a modifier to unbundle it from its comprehensive code. You can unbundle codes with a status indicator of 1, using modifier -59 (Distinct procedural service), if the circumstances and documentation substantiate unbundling it.