General Surgery Coding Alert

Learn when it's OK to unbundle and increase your reimbursement potential If you're reporting two or more distinct services, you can often legitimately override NCCI edits by applying the proper modifier, thus increasing reimbursement and the accuracy of the medical record. Must-Know Point 1: What Are NCCI Edits? NCCI edits are pairs of CPT or HCPCS Level II codes that Medicare (and many private payers) will not reimburse separately except under certain circumstances. Medicare applies the edits to services billed by the same provider for the same beneficiary on the same date of service, says Barbara Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a medical billing company in Brick, N.J. Example: The most recent edition of NCCI (version 10.2) includes edits pairing thrombectomy of arteriovenous fistula (36831) with open revision of arteriovenous fistula (36832). This would mean the surgeon could not report 36831 and 36832 for the same patient on the same day and expect to receive reimbursement for both procedures. Point 2: What Does 'Mutually Exclusive' Mean? NCCI contains two types of edits: mutually exclusive and "column 1/column 2" (previously known as "comprehensive/component" edits). Mutually exclusive edits pair procedures or services that the physician could not reasonably perform at the same session on the same beneficiary, says Kelly Dennis, CPC, EFPM, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla. For example, NCCI lists 19102 (Biopsy of breast; percutaneous, needle core, using imaging guidance) as mutually exclusive of 19100 (... percutaneous, needle core, not using imaging guidance [separate procedure]). The provider would not expect that the surgeon would provide both services on the same date at the same anatomic location for the same patient. If you were to report two mutually exclusive codes for the same patient during the same session, Medicare would reimburse only for the lesser-valued of the two procedures (in the case of 19100 and 19102, the payer would reimburse only 19100). Point 3: How Do 'Column 1/Column 2' Edits Differ? Column 1/column 2 edits describe "bundled" procedures. That is, CMS considers the code listed in column 2 as the "lesser" service, which is included as a component of the more extensive column 1 procedure. Example: The NCCI contains an edit bundling 49550 (Repair initial femoral hernia, any age; reducible) to 49500 (Repair initial inguinal hernia, age 6 months to under 5 years, with our without hydrocelectomy; reducible). In this case, 49500 is the more extensive procedure, which includes the "lesser" procedure 49550.

If you were to report bundled (column 1/column 2) procedures for the same patient during the same session, Medicare would reimburse only for the higher-valued of the two procedures (in the case of 49500 and 49550, the payer [...]