Medicare Compliance & Reimbursement

The Correct Coding Initiative (CCI) offers guidance on which codes you shouldn't bill to Medicare together, and which you can report together with modifiers.

But there are exceptions to every rule, and Medicare wants to make sure your coding doesn't fit one of these potential exceptions.

Medicare carriers routinely review claims to determine whether your physician reported codes together properly  -- meaning that you should only report the most accurate codes, and you shouldn't bill "extra" codes just because CCI allows it.

"Separate sites include bone marrow aspiration and biopsy in different bones or two separate skin incisions over the same bones," the CCI manual indicates. "When both a bone marrow biopsy (38221) and a bone marrow aspiration (38220) are performed at the same site through the same skin incision, only the bone marrow biopsy (38221) should be reported."

Endoscopy/laryngoscopy: A modifier such as 59 (Distinct procedural service) is allowable on the edit bundling 31231 (Nasal endoscopy, diagnostic...) and 31575 (Laryngoscopy, ... diagnostic). However, you can use the modifier to separate this bundle only if the physician performs the procedures during separate encounters. "The CCI edit bundling these codes assumes the physician is performing the procedures on separate sites," Cobuzzi says.

Therefore, you should avoid billing these codes together unless the physician performed the procedures during separate sessions.

Discharge with OB codes: Some ob-gyn coders believe that when a physician discharges an obstetric patient, he can report the discharge (e.g., 99238) along with the routine obstetric care code (e.g., 59510).

Reality: Code 59510 includes all routine antepartum care, the delivery, and all routine post partum care, so all daily visits in the hospital, including the day of discharge, are included in 59510. You should not try to unbundle this scenario with any modifiers.

Bottom line: Never bill Medicare for services that are considered bundled under the CCI guidelines unless they meet the pre-specified criteria allowable. Otherwise, your insurer could consider it fraudulent billing, even if the payer doesn't reimburse you for the charge.