Medicare Compliance & Reimbursement

How to get extra reimbursement for bundled codes.

Good news: Under 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.

For example, two new NCCI 12.2 edits have a modifier indicator of 0:

• The edit that bundles 93741 (Electronic analysis of pacing cardioverter-defibrillator [includes interrogation, evaluation of pulse generator status, evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response]; single chamber or wearable cardioverter-defibrillator system, without reprogramming) into 93742 (... single chamber or wearable cardioverter-defibrillator system, with reprogramming).

• The edit that bundles 93743 (... dual chamber, without reprogramming) into 93744 (... dual chamber, with reprogramming).

In other words, Medicare and other payors that follow NCCI edits will always deny 93741 when you bill it with 93742. The same goes for when you bill 93743 with 93744.

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 instance, if they occur in separate anatomic locations or during different sessions).

Example 1: The new NCCI 12.2 edit that combines 75960 into 78594 has a 1 modifier indicator. To override this edit, your cardiologist must have documentation to show how both of these procedures were significantly different from each other if the cardiologist performs them on the same patient during the same day.

For instance, if the doctor is embolizing one artery and stenting another, he could secure reimbursement for both services by attaching modifier 59 (Distinct procedural service) to 75960.

This is because the above- referenced NCCI edit has an indicator of 1, which means you can bypass it with an appropriate modifier.  

Step 2: Append the modifier to the correct code. You can append modifier 59 to the column 2 code to indicate to the payer that the billed procedures are distinct and separately identifiable, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, NJ.

Example 2: You can also separate the edit that bundles the ECG code 93040 into single-chamber pacemaker check 93735. So if your cardiologist performs a single- chamber pacemaker check and then the patient returns later with palpitations that warrant an ECG, you should append modifier 59 to 93040. The reason is that 93040 represents the column 2 or the lesser-procedure code. 

Resource: You can stay up-to-date on NCCI changes in two ways:

1) Access updates at the CMS Web site: www.cms.hhs.gov/physicians/cciedits/default.asp; or

2) purchase a subscription to the NCCI from the National Technical Information Service (NTIS) Web site: www.ntis.gov/products/families/cci.