Oncology & Hematology Coding Alert

Don't forget the 'same provider' aspect of CCI-bundled codes.

Correct Coding Initiative (CCI) edits are a fact of life for coders, and they come with a rule book all their own. Here's a quick reminder of when CCI says it's OK to report two codes from an edit pair on the same claim.

How it works: CCI edits are updated quarterly. They are created for Medicare, but many private payers apply the edits, as well. "All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2)," explains Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, consultant with MJH Consulting in Denver. The general rule is that "codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1, unless the edits permit the use of a modifier associated with CCI."

A "0" indicator means that you cannot unbundle the two codes under any circumstances. An indicator of "1" means that you may use a modifier to override the edit, but only if the clinical circumstances warrant separate payment and the documentation supports the description of the modifier you apply.

Tip: Modifier 59 (Distinct procedural service) is one of the modifiers practices most commonly use to override edits, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Hospital & Network Oversight at Mount Sinai Medical Center Compliance Department in New York City.

To use modifier 59, "documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual," Mac says. "However, when another already established modifier is appropriate [such as an anatomical site modifier], it should be used rather than modifier 59."

You can learn more by reviewing the NCCI Policy Manual and Modifier 59 Article, both available from www.cms.gov/NationalCorrectCodInitEd/.

Helpful hint: Veteran coders recommend reading the CCI chapter guidelines annually to refresh your knowledge regarding rules for each section. You may even see something new or gain a better understanding of why the edits are in place.