Gastroenterology Coding Alert

Question: Sometimes I cannot find my two-code pair in the CCI edits. In the CCI edits, how do I know which code would be considered a column 1 code and which would be considered a column 2 code? I can't seem to know where to place my modifier properly.

Massachusetts Subscriber

Answer: If you cannot find your two-code pair in the list of Correct Coding Initiative (CCI) edits, it means the codes are not bundled. You would not need a CCI modifier, such as 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), to override the edit when appropriate.

Not so fast: Just because a code does not have a bundle in CCI does not mean a modifier is out of the picture. While you won't need a CCI modifier to override the edit, you might need a payment modifier.

You can find Medicare's other allowed modifiers for any given CPT® code in the Medicare Physician Fee Schedule (MPFS). Columns Y-AC indicate if modifier 51 (Multiple procedures), 50 (Bilateral procedure), etc. apply.

To determine which code receives modifier 51, you need to know the code's relative value units, which are also listed in the MPFS. Private payers may not adjust claim items in descending order as Medicare's Outpatient Code Editor software does. If you append modifier 51 to a higher valued item, the private payer may apply the adjustment based on your coding, costing you payment. You should instead list the items in descending relative value order from highest to lowest. Append modifier 51 to the lower priced procedure as necessary. The insurer will then apply the typical 50 percent, multiple procedure reduction to the lower priced code.