General Surgery Coding Alert

The national Correct Coding Initiative (CCI), first issued in January 1996 and updated each quarter since then, has become an essential source of coding information.

"If you perform more than one procedure during the same session, you have to check if the procedures are bundled. For that you need the most recent edition of the CCI," says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. "Relying on an outdated edition of CCI is like relying on last year's CPT. Maybe worse. You don't know when CCI will add hundreds, even thousands, of new code pairs."

CCI code pairs are defined as either "incidental" (also known as comprehensive/ component edits) or "mutually exclusive." Incidental services/procedures ("component" codes) are considered a part of another, more extensive service/procedure ("comprehensive" codes). A procedure or service is not normally separately reimbursable if reported with a comprehensive code into which it is bundled.

A single procedure or service may be both a comprehensive code and a component code. For instance, exploration code 35820 (Exploration for postoperative hemorrhage, thrombosis or infection; chest) bundles three component codes, including +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]) and others, but is itself a component of dozens of codes (for example, aneurysm repair codes 35021 and 35022). This means 69990 is also "indirectly" bundled into the same codes.

Note: A complete explanation of Medicare bundling policies can be found in section 15010 of the Medicare Carriers Manual (MCM). The MCM can be downloaded free from the CMS Web site at http://cms.gov.

Mutually exclusive code pairs represent procedures/ services that, based on standard medical practice or CPT guidelines, usually cannot be performed "at the same session by the same provider on the same patient," according to CMS. These code pairs are divided into "column 1" and "column 2" designations. The codes in column 2 represent the procedures/services that cannot reasonably be done in the same session as the procedure/service listed in column 1, CCI says, and therefore would not be recognized, i.e., only the column 1 code will be paid. For instance, a surgeon would not take a breast biopsy both with (19102) and without (19100) imaging guidance for the same location during the same session. In this case, 19100 is the column 1 code, and therefore the payer would ordinarily reimburse for the service if reported with 19102.

In addition, all component and column 2 codes include a Correct Coding Edit Modifier Indicator, usually a "0" or "1." According to CCI, a 0 "indicates that there are no circumstances in which a modifier would be appropriate. The services represented by the code combination will not be paid separately." These code combinations may never be unbundled.

On the other hand, a 1 indicates "that a modifier is allowed to differentiate between the services provided." In most cases, modifier -59 (Distinct procedural service) is appropriate to unbundle CCI edits and allow for separate payment. In accordance with Medicare policy, however, "Modifier -59 should be used only when no more descriptive modifier (such as an anatomic modifier or the staged procedure modifier) is available."

For instance, the surgeon performs excision of the greater saphenous vein on the left side (37720 Ligation and division and complete stripping of long or short saphenous veins) and an excision of secondary clusters on the lesser saphenous vein (37785 Ligation, division and/or excision of recurrent or secondary varicose veins [clusters], one leg) at a different site. Normally, 37720 and 37785 are bundled, but in this case modifier -59 is appropriately appended to 37720 to indicate that the two procedures normally not billed together were performed at different locations in the body.

Note: The CCI is available by subscription from the National Technical Information Service (NTIS) in print or as a CD-ROM in searchable (.pdf) format. Contact NTIS (1-800-363-2068 or http://www.ntis.gov/products/hcfa.htm) for more information.