Medicare Compliance & Reimbursement

Tip: Familiarize yourself with private payer policies to ensure steady pay.

It's no secret that Medicare's Correct Coding Initiative (CCI) creates edit pairs to indicate which CPT^® and HCPCS codes you should normally avoid reporting together.

But did you know that CCI is more than just a list of codes? Read on to learn our experts' tips and tools that will help you file clean claims and optimize your Medicare pay.

Utilize Your Resources

The CCI program provides specific compliance instruction in the annually-updated NCCI Policy Manual. Here, you'll find "general rules for all coding concepts and rules for each CPT^® chapter," says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, manager of clinical compliance with PeaceHealth in Vancouver, Washington. "Read through these rules and be sure you understand the concepts for the chapters you work in most often. This will help you understand what is likely to bundle and will guide you even if you don't have software that tells you when you make a bundling error."

Ongoing education through newsletters, periodicals, and reference books is also important for CCI edit success, says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, staff services coordinator/billing/credentialing/auditing/coding at County of Stanislaus Health Services Agency in Modesto, California.

For instance: "Investing in good software or programs that will let you easily cross-check codes against each other is a huge time-saver," Johnson adds.

Know payers' policies: Remember that the CCI edits were created for Medicare and most government payers, so, it's important to know how your commercial payers utilize these edits - if at all.

Document Exceptions to Allow Edit Override

For bundled procedures with a "1" modifier indicator, you might be able to override the edit-pair and get paid for both services.

Conditions: If the bundled tests represent specimens from different anatomic sites or different surgical sessions, and you have written documentation to that effect, you can list both services on the claim and report the column-2 code with a modifier such as 59 (Distinct procedural service).

"If documentation supports reporting both procedures (with modifier), and one procedure is denied, always appeal," says Dolly Perrine, CCS-P, CPC, CPC-I, CUC, CPMA, auditor and educator of professional services at St. Charles Health System in Bend, Oregon. "I have found that if I have supporting documentation and the claim is denied due to bundling, if I appeal, it would most always be paid." She adds, "I'm aware that it takes additional time to appeal, but once again, that's money left on the table."

Editor's note: Codify offers a CCI Edits Checker tool that makes checking your claim for CCI edit conflicts as efficient as possible. Try a 14-day free trial here: https://www.aapc.com/codify/cci-edits.aspx.