Neurosurgery Coding Alert

Learn when it's OK to unbundle and increase your reimbursement potential

If you're reporting two or more distinct services, you can often legitimately override NCCI edits by applying the proper modifier, thus increasing reimbursement and the accuracy of the billing record.

NCCI edits are pairs of CPT or HCPCS Level II codes that Medicare (and many private payers) will not reimburse separately except under certain circumstances. Medicare applies the edits to services billed by the same provider for the same beneficiary on the same date of service, says Barbara Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a medical billing company in Brick, N.J.

Example: The most recent edition of NCCI (version 10.2) includes edits pairing needle electromyography (EMG) (95860-95861 and 95867-95868) to spinal injections (64400-64530), among others. This would mean that under most circumstances, the neurosurgeon could not report EMG and spinal injections for the same patient on the same day and expect to receive reimbursement for both procedures.

NCCI contains two types of edits: mutually exclusive and "column 1/column 2" (previously known as "comprehensive/component" edits).

Mutually exclusive edits pair procedures or services that the physician could not reasonably perform at the same session on the same beneficiary, says Kelly Dennis, CPC, EFPM, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla.

As an example, NCCI lists 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) as mutually exclusive of 61313  (... intracerebral). The provider would not expect that the surgeon would perform both types of craniectomy on the same date for the same patient because they describe different, exclusive procedures. In theory, the surgeon could not perform an intracerebral hematoma removal without removing the subdural (at least at the same site), and therefore you should not report these procedures separately.

If you were to report two mutually exclusive codes for the same patient during the same session, Medicare would reimburse only for the lesser-valued of the two procedures (in the case of 61312 and 61313, the payer would reimburse only 61312).

Column 1/Column 2 edits describe "bundled" procedures. That is, CMS considers the code listed in column 2 as the "lesser" service, which is included as a component of the more extensive, column 1 procedure, Cobuzzi says.

Example: The NCCI contains an edit bundling 61535 (Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue [separate procedure]) to 61320 (Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial).

In this case, 61320 is the more extensive procedure, which includes the "lesser" procedure 61535. In theory, removing the electrode array is not significant enough to warrant separate payment when done at the same time as the abscess drainage.

If you were to report bundled (column 1/column 2) procedures for the same patient during the same session, Medicare would reimburse only for the higher-valued of the two procedures (in the case of 61320 and 61535, the payer would reimburse only 61320).

Yes, in certain circumstances you may override NCCI edits and achieve separate reimbursement for mutually exclusive or column 1/column 2 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. The edit bundling 61320 (craniectomy) and 61535 (craniotomy), for instance, includes a "0" modifier indicator, meaning that you may never override that particular edit.

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 example, the edit bundling electromyography (EMG) 95860 to spinal injection 64400 (discussed in point 1, above) includes a "1" modifier indicator. This means that if the EMG occurs at a different location than the spinal injection (in other words, for a reason other than to guide the spinal injection) you may report the services independently.

Step 2: Verify that the procedures are distinct. You should only attempt to override NCCI code pair edits if the paired procedures are separate and unrelated, Cobuzzi says. For instance, the physician may have provided the services/procedures at different sessions, at different anatomic locations, or for different diagnoses.

Example: The neurosurgeon performs a laminectomy with foraminotomy (63047, ... unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] ...; lumbar), with a hemilaminectomy and diskectomy at a different level (63030, ... with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar ...). Because the procedures occur at different levels (that is, separate anatomic locations), you may report both procedures.

Step 3: Append modifier -59: Finally, you must append modifier -59 (Distinct procedural service) to the column 2 code to indicate to the payer that the billed procedures are distinct and separately identifiable, says Beth Glenn, CPC, CMA, certified coder for Jefferson Physicians in Jefferson City, Tenn. "Without modifier -59, the payer will simply apply the NCCI edits and deny payment," she says.

In the example given in step 2 of a separate laminectomy and hemilaminectomy, you should report 63047 and 63030 with modifier -59 appended.

CMS updates the NCCI every quarter. The number of changes each quarter varies, but almost every update contains significant changes. "You'll always want to be sure to be using the latest edition of NCCI," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "If you're one or two versions behind, you could be coding incorrectly and not even know it."

You can stay up-to-date on all NCCI changes in one of two ways:

You can access NCCI updates through the CMS Web site at www.cms.hhs.gov/physicians/cciedits/default.asp. The CMS Web site contains a listing of the NCCI edits, by specific CPT sections, and is available as a free download.

Or, you may purchase a quarterly or yearly subscription to the NCCI from the National Technical Information Service (NTIS) Web site at www.ntis.gov/products/families/cci, or by contacting NTIS at (800) 363-2068 or (703) 605-6060.