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.

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.

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).

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 would reimburse only 49500).

Yes, in certain circumstances you may override NCCI edits and achieve separate reimbursement for bundled codes.

Step 1: Check the correct coding modifier indicator. Each NCCI code pair edit includes a correct coding modifier indicator of 0 or 1.

A "0" indicator means that you may not unbundle the edit combination under any circumstances, according to NCCI guidelines. The edit bundling thrombectomy of arteriovenous fistula (36831) to open revision of arterio-venous fistula (36832), for instance, includes a "0" modifier indicator -- meaning that you may never override that particular edit.

An indicator of "1," however, means that you may use a modifier to override the edit if the procedures are distinct from one another. For example, the edit bundling breast biopsy with imaging guidance (19102) to biopsy without guidance (19100) includes a "1" modifier indicator. This means that if the biopsy with guidance occurs at a different location than the biopsy without guidance (for instance, one service occurs on the left breast and the other on the right breast), you may report the services independently.

Step 2: Verify that the procedures are independent and distinct. You should attempt to override NCCI code pair edits only if the paired procedures are separate and unrelated, Cobuzzi says. For instance, the physician may have provided the services/procedures at different sessions, at different anatomic locations or for different diagnoses.

Example: NCCI bundles 37785 (Ligation, division and/or excision of varicose vein cluster[s], one leg) into 37720 (Ligation and division and complete stripping of long or short saphenous veins). This means that if the surgeon performs the ligation of secondary varicose veins on the same blood vessel(s) as he performs complete stripping, you may not report the secondary ligation separately (this would represent "double-billing").

But if the surgeon performs ligation of secondary veins on a blood vessel(s) that's separate from where he performs complete stripping, you may claim 37785 in addition to 37720. You should link an appropriate diagnosis to each code, and your documentation should support the independent nature of 37785 (that is, the documentation should make clear that the procedures occurred at different anatomic locations).

Step 3: Append modifier -59: You must append modifier -59 (Distinct procedural service) to the column 2 code to indicate to the payer that the billed procedures are distinct and separately identifiable, says Beth Glenn, CPC, CMA, certified coder for Jefferson Physicians in Jefferson City, Tenn. "Without modifier -59, the payer will simply apply the NCCI edits and deny payment," she says.

In the example given in step 2 of a separate secondary vein stripping with complete vein stripping, you should report 37720 (complete stripping) and 37785 (stripping of secondary veins) with modifier -59 appended.

CMS updates the NCCI every quarter, and you should always consult the most recent version when coding.

The number of changes each quarter varies, but almost every update contains significant changes. "You'll always want to be sure to be using the latest edition of NCCI," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "If you're one or two versions behind, you could be coding incorrectly and not even know it."

You can stay up-to-date on all NCCI changes in one of two ways:

You can access NCCI updates through the CMS Web site, www.cms.hhs.gov/physicians/cciedits/default.asp.

The CMS Web site contains a listing of the NCCI edits, by specific CPT sections, and is available free for downloading to the public.

Or, you may purchase a quarterly or yearly subscription to the NCCI from the National Technical Information Service (NTIS) Web site at www.ntis.gov/products/families/ncci, or by contacting NTIS at (800) 363-2068 or (703) 605-6060.