Gastroenterology Coding Alert

For the past two years, the Health Care Financing Administration (HCFA) used both published and unpublished edits computer instructions developed to help Medicare payers identify improper claims. The published edits are listed in the Correct Coding Initiative (CCI), which is updated and printed on a quarterly basis. The unpublished edits are referred to as black box edits.

CCI Edits Still in Effect

The CCI contains a list of procedures that Medicare considers to be components of a more comprehensive procedure. The codes for these component procedures are bundled by the CCI into the codes for the comprehensive procedures. These bundled coding combinations are not reimbursable separately unless the component procedure represents a distinct procedure or service from others billed on the same date of service, according to the Medicare Carriers Manual (MCM). The manual goes on to state that this distinct procedure or service may represent a different session, different surgery, different anatomical site or organ system, separate incision/excision, different agent, different lesion, or different injury or area of injury.

Commercial Edits Expire on Oct. 1

In October 1998, to realize what HCFA administrator Nancy-Ann Min DeParle estimates to be $205 million in savings, HCFA put an additional 500 procedure-to-procedure edits into effect to further ensure that Medicare did not pay separately for services that should be paid together. According to DeParles testimony before a committee of the U.S. House of Representatives in May 1998, these edits were developed with commercially available off-the-shelf software and, as a result, are often referred to as commercial edits.

HCFA declined to publish this list of commercial edits because of what DeParle referred to in her testimony as ownership issues and the need to stay ahead of unscrupulous providers. In the MCM, local payers were instructed that Commercial edits are not part of the CCI. The commercial edits are proprietary, and may not be made available to the public in a mass publication like CCI. Upset over the use of edits that were not available for public review, the American Medical Association passed a resolution criticizing the commercial edits and called them the black box edits.

HCFA chose not to renew its contract with HBO & Co., the software vendor that supplied the edits, according to Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. HCFAs contract with HBO & Co. expires on Oct. 1.

Removal Is Not Retroactive

Gastroenterologists still need to monitor claims that were filed before the Oct. 1 effective date, says Callaway-Stradley. The removal of the black box edits is not retroactive and only affects claims filed after the effective date, she cautions.

Many coding experts believe the colonoscopy with biopsy code (45380) was bundled with the polypectomy codes 45384 (colonoscopy with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) and 45385 (colonoscopy with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) in the commercial edits. There also have been suspicions that 45384 and 45385 were bundled together.

Callaway-Stradley cautions, however, that just because a gastroenterologist feels a particular coding combination was a black box edit does not mean that it will be reimbursed in the future. Many of the so-called black box edits are really standard edits, she explains. Even if they are not listed in the CCI, there are procedures that are considered standard components of other procedures by CPT, and these still will not be separately reimbursable.