Gastroenterology Coding Alert

Question: What advice can you offer for finding a particular code-pair when I am checking through CCI edits? How do I know which among the two is the column-1 code and the column-2 code?

New Jersey Subscriber

Answer: If you are not finding the code-pair in the Correct Coding Initiative (CCI) edit lists, then it can be assumed that the two codes are not bundled. In such a scenario, you will not require the use of a CCI modifier like 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), 57 (Decision for surgery) or 59 (Distinct procedural service). These modifiers are of use when a CCI edit is in place to help in overcoming the edit and receive payments as is appropriate for both the claims.

Reminder: Although some code pairs are bundled in the CCI edit lists, it may not be essential for you to use a modifier in every reporting scenario. There may be instances where in you may not have to use a modifier to overcome the edit but you may still have to use a modifier to get appropriate payments.

If the payer for your claims is Medicare, then you might use modifiers that are found in the Medicare Physician Fee Schedule (MPFS). Some of the modifiers that you will have to use in such a scenario might include 50 (Bilateral procedure) or 51 (Multiple procedure).

Pay attention to the individual RVUs (Relative value units that are found in the MPFS lists) for determining which of the codes you will attach a modifier such as 51.

If you just blindly apply the modifier to one of the two codes and if that code is the one that has a higher RVU, then you end up losing out on payment. So, it is essential to know the RVU of both the reported codes and append the modifier to the code that has the lesser RVU. Then, this procedure will receive 50 percent of payment while the other procedure will be paid at 100 percent.