Neurology & Pain Management Coding Alert

Each time the Correct Coding Initiative (CCI) releases an update, new edits and deleted pairs get a lot of the attention. But if you ignore the swapped pairs in version 16.1, which took effect on April 1, you could be missing out on deserved reimbursement when your neurologist performs an electromyography (EMG) exam with intraoperative monitoring.

Version 16.1 is the second Correct Coding Initiative (CCI) update of the year.CCI 16.1 includes 2,054 new active pairs and 1,947 modifier changes, says Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions, Inc. in Clearwater, Fla.

"With each of the quarterly CCI updates, practices tend to primarily focus on the new CCI edits that they will have to deal with. They may not even consider that there'sa potential swap in the columns, and the need to change which code should have the modifier appended," says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACSPM, CHCO, owner of MJH Consulting in Denver.

Keep reading and you'll come away with what you need to know about the top CCI 16.1 swapped pairs edits that will affect your neurology practice.

One example of the importance of swapped pairs in CCI 16.1 occurs with greater occipital nerve (GON) injections. If your neurologist performs an injection on a patient's GON (64405, Injection, anesthetic agent; greater occipital nerve) and also performs a tendon injection in a separate anatomic location, such as the thumb for De Quervain's syndrome (20550, Injection[s]; single tendon sheath, or ligament,aponeurosis [eg, plantar "fascia"]), you'll need to know that the two codes have switched places.

Reasoning: The logic behind this kind of CCI edit is that the more extensive procedure is now in column 1.

The result: For example, 20550 is now the column 2 code, with 64405 in column 1. "It makes more sense, because you don't do greater occipital nerve injections as an anesthetic injection as a part of the tendon injection," Hammer says. This edit carries a "1" modifier indicator.

The same concept applies to other codes as well,including 62360 (Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir), 62361 (... nonprogrammable pump) and 62362 (... programmable pump, including preparation of pump, with or without programming) moving to the column 1 position and 62365 (Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion) which was swapped to the column 2 position. These swapped pairs carry the "0" modifier indicator.

Reminder: A modifier indicator of "0" means that you cannot unbundle or break the pair with any modifier. A modifier indicator of "1" means that you may be able to unbundle if medical necessity calls for it, and you have the proper documentation from your neurologist's notes.

Some EMG codes have also received important swapped pair updates in CCI 16.1. For example, if your neurologist performed a three-extremity EMG (95863, Needle electromyography; 3 extremities with or without related paraspinal areas), and then later that day performed intraoperative monitoring (IOM) when the patient went into surgery (+95920, Intraoperative neurophysiology testing, per hour [List separately in addition to code for primary procedure]), the way you'll report these codes has now changed.

Here's how: If your neurologist's documentation supports separately reporting 95863 and +95920 because he performed IOM in a separate and distinct sessionfrom the EMG diagnostic study, you now have to report modifier 59 (Distinct procedural service) with +95920, the new column 2 code.

Reasoning: Based on both the CPT manual and CMS coding manual instructions, CMS has exchanged which of these two procedures is considered the component of the other. +95920 is an add-on code, meaning it can never be reported as a stand-alone code. The code for the three extremity EMG diagnostic study (95863) is not in the list of the acceptable primary or "parent" CPT procedure codes for the IOM add-on code.

Important: Even if you have all the right CPT and ICD-9 codes, if you put the modifier on the wrong code, your payer's system will likely deny it automatically. Be sure to double-check your modifier placement before sending the claim.

Check Out Infusion Changes Before Using Modifier 25

Although neurologists do not typically infuse chemotherapy, they can administer similar medications for treatment of conditions such as multiple sclerosis (MS), Hammer says. So you'll need to check out 16.1's swapped pair changes to codes such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

Old way: In the past, if a patient underwent an infusion, you reported 96413. But if the patient had complications and was admitted to a hospital, you also reported the appropriate initial hospital care E/M code (99221-99223, Initial hospital care, per day ...) for your neurologist's E/M services. You would then append it with modifier 26 (Professional component) to bypass the applicable CCI edit.

New way: As of April 1, you will need to append modifier 59 to 96413, "if it's indeed separate and distinct," Hammer advises. The 16.1 CCI edits move 96413 into the column 2 position. The change was also made retroactive back to the original 4/1/2008 effective date. This is extremely significant if you are working on denials for 96413 with an E/M service. You not only need to understand which code to append the modifier to, but also whether you need to use modifier 25 or modifier 59.