Ob-Gyn Coding Alert

Hint: Be very careful when using a modifier to break an edit.

You just learned about upcoming CPT^® changes, and when you get new codes, you’ll get new National Correct Coding Initiative (NCCI) edits in January. Prepare for this eventuality by reviewing this NCCI primer. You’ll be doubly prepared when January 1 hits.

In the recent webinar, “The National Correct Coding Initiative and Medically Unlikely Edits,” Arlene Dunphy, provider outreach and education consultant at the Medicare administrative contractor (MAC) National Government Services (NGS), gave helpful tips on how procedure-to-procedure (PTP) NCCI edits work, including why modifier indicators are important.

Editor’s note: There are two types of PTP edits, those for physicians and those for hospitals. We will be talking only about the PTP edits that impact physicians.

Follow these four tips and get back to the basics with PTP NCCI edits in your ob-gyn practice.

Tip 1: Focus on Why NCCI PTP Edits Matter

PTP pair edits, which are updated quarterly, are just one type of NCCI edits. There are also medically unlikely edits (MUEs) and add-on codes.

“PTP edits were developed to promote national correct coding methods, to control improper coding leading to inappropriate payments for Medicare claims, and to prevent unbundling of services,” Dunphy said.

NCCI’s coding policies are based on the CPT^® manual, the HCPCS manual, national and local Medicare policies, and coding guidelines that national societies developed.

Where to find: You can find the latest NCCI edits at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd. The most recent edits were effective on April 1.

Tip 2: Puzzle Out How PTP Edits Work

In PTP edits, when your provider submits the two codes, the Column 1 is eligible for payment, but Medicare will deny the Column 2 code unless both codes are clinically appropriate, according to Dunphy. Also, your provider must include the supporting documentation in the medical record.

NCCI does not include all possible code combinations, so providers are obligated to code correctly, even if edits do not exist, Dunphy said. Services that are denied based on PTP code pair edits may not be billed to Medicare beneficiaries, and you cannot utilize an advance beneficiary notice (ABN) to seek payment.

Tip 3: Pinpoint Different Modifier Indicators

Each PTP edit pair has a particular modifier indicator. This indicator can be “0,” “1,” or “9.” Take a look at what these indicators mean:

• Indicator 0 — These codes should never be reported together by the same provider for the same beneficiary on the same date of service (DOS).
• Indicator 1 — These codes may be reported together only in defined circumstances (identified on claims by specific NCCI-associated modifier).
• Indicator 9 — Not relevant. The edit was deleted.

Example: Code 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed) is a Column 2 code to 57285 (Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach), so they are bundled together. However, since the modifier indicator for this PTP edit pair is “1,” you may break the edit with a NCCI-associated modifier under appropriate circumstances.

Bottom line: When it comes to PTP edit pairs, the Column 1 code is payable, and the Column 2 is a component code that is only payable if certain criteria are met, according to Dunphy.

Tip 4: Append NCCI-Associated Modifiers Appropriately

Modifier 59 (Distinct procedural service) is probably the most well-known modifier when it comes to PTP edits. However, modifier 59 is also a widely abused modifier that some may use just to bypass an edit, so make sure you append this modifier appropriately, Dunphy said.

Also, documentation is key when you are using modifiers. The supporting documentation must satisfy the criteria required.

“Only use this modifier if it [modifier 59] best describes the circumstances,” Dunphy adds. You should never just use modifier 59 as a default modifier.

X{EPSU}modifiers: Modifiers XE (Separate encounter…), XS (Separate structure…), XP (Separate practitioner…), and XU (Unusual non-overlapping service…) are a subset of modifier 59, but they have not replaced modifier 59.

You should never report modifiers X{EPSU} together with modifier 59 on your claim, Dunphy said. You should just report one modifier or the other.

Here are some tips from Dunphy about appropriate use for modifiers 59 and X{EPSU}. Use modifier 59 or X{EPSU}:

• For a different session or patient encounter, different procedure or surgery, different anatomical site, or separate injury or area of injury.
• When the medical record documentation indicates two separate distinct procedures performed on the same day by the same physician.
• When there is no other appropriate modifier to use. 

On the other hand, you should never use modifiers 59 or X{EPSU} under the following circumstances:

• If the code combination does not appear in the NCCI edits.
• You should not append these modifiers to an evaluation and management (E/M) service performed on the same date. In that case, you should look to an E/M modifier such as modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).
• If the PTP edit has a modifier indicator of “0,” you cannot use a modifier to break the edit.
• If the medical record documentation does not support the separate and distinct status, you cannot use a modifier.
• If the provider performed the exact same procedure code twice on the same day, you should instead look to modifiers 76 (Repeat procedure or service by same physician or other qualified health care professional) or 77 (Repeat procedure by another physician or other qualified health care professional).