General Surgery Coding Alert

Know when '0' means 'no.'

If you're getting suspicious denials for laparoscopic lymphadenectomy or proctectomy procedures, you might be caught in the web of new Correct Coding Initiative (CCI) edits that became effective April 1.

Check out the following code bundles you need to know, as well as "modifier indicator" tips to help you maneuver the present CCI coding landscape.

Forget About Modifier 59 With Proctectomy Bundles

The latest edition of CCI changes the modifier indicator on the following bundles to "0," which means you can no longer separate the edits under anycircumstances, even when using a modifier such as 59 (Distinct procedural service).

• 45395 (Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy) always bundles into colectomy codes 44143, 44145, 44146, 44150-44155, 44208, and pelvic exenteration code 45126. Code 45395 is the column 2 code in these scenarios with a modifier indicator of "0," which means you'll never get paid for 45395 when you report it with one of these other codes.
• Colectomy codes 44156, 44207, and 44210-44212 always bundle into 45395. In this situation, 45395 is the column 1 code and you can expectpayment for 45395 but not the bundled procedures if you report them together.

Beware Lymphadenectomy Bundles, Too

Before you start reporting additional codes with 38573 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed), you might want to take a moment to consider CCI edits added in version 24.0 and 24.1 for January and April, 2018.

You'll find a lot of codes combined with this one - and here's the rub: You can't use a modifier to bypass these bundles, either.

For instance, CCI adds debridement codes +11001-11006 and 11042-+11047, as well as lymph node codes 38562-38572, as column 2 codes with 38573. Also be alert for omentum and peritoneum codes 49255, 49320, +49326, and 49400 as column 2 codes with 38573. CCI lists all of these bundles with a "0" modifier indicator.

These edits mean that the additional CPT^® code includes the procedures listed in 38573, says Melanie Witt, MA, RN, an independent coding expert based in Guadalupita, New Mexico.

When Modifier Indicator Is "0," Don't Consider ABN

The CCI was created to assist physicians in correctly coding their services for reimbursement, said CGS Medicare's Vanessa Williams during a March 28 webinar entitled "Correct Coding Initiative and Medically Unlikely Edits."

Lowdown on the bundles: One type of CCI error is unintentional, which results from a misunderstanding of coding, Williams said. The second is intentional, "when the technique is used by the provider to manipulate coding in order to maximize reimbursement," she explained. In addition, some coders will report multiple codes when one code would actually cover all of the services performed, which is also marked as an error under the CCI rules, she said.

Modifier Indicators: If a code pair has a "0" modifier indicator, "it is something that cannot be submitted separately," Williams said. "In addition, the beneficiary cannot be responsible for the reimbursement of that code in column 2, and the beneficiary cannot be billed for that service, not even with an advance beneficiary notice," she said.

A "1" modifier indicator, however, indicates that you can append a modifier such as 59, 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service), or one of the "X" modifiers to separate the bundle, but only if you have supporting documentation in the medical record of the separate services.

A modifier indicator of "9" means that no CCI edit applies to that code pair, although it's possible that a bundle previously applied to the pairing and was later deleted.

Resource: To review the CCI edits on the CMS website, visit https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.