Neurology & Pain Management Coding Alert

Due to a large number of errors, the implementation of the national Correct Coding Initiative (CCI) version 6.1 has been delayed from April 1 to May 1, 2000. Users of any CCI edit products should make certain that they have a corrected copy of version 6.1 before its implementation on May 1, either in the form of an errata sheet or, in some cases, an updated book, says Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting, a physician consulting firm in Manassas, Va.

The National Technical Information Service (NTIS) publishes the CCI edits, along with several other commercial resellers who purchase the raw data from NTIS. According to NTIS, all of their customers, including subscribers and resellers, received an errata sheet soon after the Health Care Financing Administration (HCFA) made the NTIS aware of the errors.

We received 37 pages of changes from NTIS, confirms Tony Mistretta, editor at Medical Management Institute, one of the licensed resellers of the CCI edits. We are not redoing our manuals or electronic products, but we are sending errata to our subscribers, he says.

Those who purchased CCI edits from another source also should look for corrections to version 6.1 in time for the May 1 implementation. For NTIS customers, this has been sent out in the form of an appendix, which must be cross-referenced to the version 6.1 product. Other resellers should have received the errata sheet from NTIS and made arrangements to get that information to their customers.

How CCI Works

In response to direction from Congress, CCI edits were initiated in 1996 to reduce Medicare program expenditures by detecting inappropriate coding on claims. The CCI edits are basically a list of code pairs that Medicare will not reimburse together for the same patient on the same day because they represent services that are bundled or would not ordinarily be performed together, explains Castillo. Reporting two of these codes together for the same service represents fraudulent unbundling, which is the practice of breaking down a single procedure into its component parts, and billing for additional services.

There are times, however, when two of these codes might legitimately be coded together, if they represent two services that are distinct and independent from each other, says Castillo. To indicate that the codes represent separate services as opposed to unbundling of a single service, coders should use appropriate modifiers, such as CPT modifier -59 (distinct procedural service).

Correct Coding Modifier 0 and 1

The CCI edits list code pairs that are excluded based on two relationships:

1. one code is comprehensive and includes the service of the other component code; or
2. the two codes are mutually exclusive, such as two different lab tests that measure the same factor.

Within the list of code pairs in the CCI edits, you will notice the use of superscript numbers 0 or 1 on some codes, says Karen Duane, CPC, coding specialist for the Barrow Neurological Institute, one of the largest full-service neuroscience centers in the southwestern United States with 20 neurologists in Phoenix.

A 0 means that a modifier would not be appropriate to allow that code pair to be reported together under any circumstances, Duane continues. For example, two electro-encephalograms (EEGs) would not be performed on the same patient at the same time. That is why if a patient be-came drowsy during an EEG that lasted more than an hour, it would not be appropriate to bill for both a 95816 (EEG including recording awake and drowsy [including hyperventilation and/or photic stimulation when appropriate]) and a 95813 (EEG extended monitoring; greater than one hour). The proper code in this instance would be 95813.

A 1 means that a modifier is allowed, if appropriate, says Duane. A patient could have two EEGs in one day that would be billed properly as distinct services. For example, an EEG used to monitor a patient during surgery that lasted more than an hour would be billed using code 95813. If the patient went into cardiac arrest later in the day and was subsequently comatose, however, another EEG might be performed to determine whether his brain was still functioning using code 95824 (cerebral death evaluation only). As such, both codes could be reimbursable when reported with modifier -59 (distinct procedural service). In fact, for any code pairs listed with a 1, Medicare requires the use of a modifier if the same physician reports them together for the same patient on the same day.

The errors in the initial release of CCI version 6.1 involved the incorrect assignment of the 0 or 1 modifier to 3,782 code pairs, says Mistretta. The vast majority (3,727 code pairs) were incorrectly assigned the 0, he continues, indicating that a modifier cannot be used to identify the services as separate and distinct. Using the uncorrected version 6.1, providers would not be allowed to bill these codes together, potentially causing significant under-reimbursement of legitimate services.
Only 55 code pairs were misidentified with a 1 instead of a 0 modifier indicator.

What to Do

The key to unraveling this situation is to make sure you are using the same CCI edits version 6.1 as your local Medicare carrier, says Castillo. Be on the lookout for the corrections and talk to your carrier to be sure you are using the same information. If you do that, the corrected errors hopefully will prove to be no more than an inconvenience until version 6.2 is released and implemented on July 1, 2000.