Ob-Gyn Coding Alert

Learn the 1 new ob-gyn-related version 12.2 edit that could affect you

If you-re still uncertain what a mutually exclusive edit is and whether you-re using the latest NCCI version in your ob-gyn practice, you could be setting yourself up for future reimbursement hassles.
 
Get a handle on the NCCI in's and out's by reading these six questions and committing their answers to memory.

Question 1: What Are NCCI Edits?

National Correct Coding Initiative 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 Kelly Dennis, MBA, CPC, ACS-AP, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla.
  
Example: The most recent edition of NCCI (version 12.2), effective July 1, includes an edit bundling therapeutic injection code 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) into 86580 (Skin test; tuberculosis, intradermal). This means that your ob-gyn could not report 90772 and 86580 for the same patient during the same session and expect to receive reimbursement for both procedures

Question 2: What Does -Mutually Exclusive- Mean?

NCCI contains two types of edits: mutually exclusive and comprehensive/component edits.
  
Mutually exclusive edits pair procedures or services that the physician would not reasonably perform at the same session, at the same anatomic location, on the same beneficiary, Dennis says.
  
Example: You-ll find that 76828 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study) is a component of 76820 (Doppler velocimetry, fetal; umbilical artery) and 76821 (... middle cerebral artery), thanks to an NCCI mutually exclusive edit.
 
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 this case, 76828 is the lesser valued procedure.

Question 3: How Does -Column 1/Column 2- Differ?

Comprehensive/component 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.
  
Example: NCCI contains an edit that bundles moderate sedation codes (99143-99149) into 58823 (Drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous [e.g., ovarian, pericolic]). In this case, 58823 is the more extensive procedure, which includes the lesser procedure -- any one of the moderate sedation codes (99143-99149). The moderate sedation is an inherent part of the procedure when performed by the same physician performing the procedure.
  
If you were to report bundled (comprehensive/component) procedures for the same patient during the same session, Medicare would reimburse only for the higher valued of the two procedures (in this case, 58823).

Question 4: Can I Ever -Override- NCCI Edits?

Yes, in certain circumstances you may override NCCI edits and achieve separate reimbursement for bundled 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.
 
For example, you cannot separate the edit that combines 44180 (Laparoscopy, surgical, enterolysis [freeing of intestinal adhesion] [separate procedure]) and 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). If you try to report 44180 and 49320 separately, you-ll receive a denial and only be reimbursed for 44180.
 
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 instance, if they occur in separate anatomic locations).
  
Example: The new NCCI 12.2 edit that combines 90772 into 86580 has a -1- modifier indicator. To override this edit, your ob-gyn would have to inject some other substance besides the TB, such as administering an intramuscular injection of Depo-Provera at the same encounter as the TB test.
  
Step 2: Append modifier 59. 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 Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.
  
So if your ob-gyn provides an IM injection of Depo-Provera (90772) at the same encounter as a TB test (86580), you should append modifier 59 to 90772. The reason is that  90772 is the column 2 code.

Question 5: When Are the NCCI Edits Updated?

CMS updates the NCCI every quarter, and you should always consult the most recent version when coding.
  
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,- Cobuzzi says. -If you-re one or two versions behind, you could be coding incorrectly and not even know it.-

Question 6: How Can I Find the NCCI Edits?

You can stay up-to-date on NCCI changes two ways:
  
You can access NCCI updates through the CMS Web site 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 free for downloading.
  
Or you may purchase a quarterly or yearly subscription to the NCCI from the National Technical Information Service Web site: www.ntis.gov/products/families/cci.