Ophthalmology and Optometry Coding Alert

Tip: Keep edits in mind for other payers besides Part B MACs.

With the new round of Correct Coding Initiative (CCI) edits going into effect as of July 1, 2011, it's a good time for a CCI refresher. Whether you're new to coding or you've been dealing with the edits for years, it can't hurt to check out the following three frequently-asked questions.

Know When Modifiers Apply

Question 1: Our office manager never allows us to use a modifier to override the CCI edits because she says that ignoring CCI edits amounts to "unbundling," which is not appropriate. But we've been using modifiers to override CCI edits for years. Who is right?

Answer: In certain clinical circumstances you can override -- not ignore -- CCI edits and receive separate payment for bundled codes. To find out if you can separately bill services, first check the "modifier indicator" in column F of the CCI spreadsheet.

How it works: "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. "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," however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate payment.

Tip: The most common modifiers that Part B practices use to override an edit pair are 25 (Significant, separately identifiable evaluation and managementservice by the same physician on the same day of the procedure or other service) when used with an associated E/M code, or modifier 59 (Distinct procedural service) when two non-E/M services are performed and no other modifier is available to report the two separate and distinct services, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Network Oversight at Mount Sinai Medical Center Compliance Department in New York City. "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," she says. "However, when another already established modifier is appropriate, it should be used rather than modifier 59."

Example: Codes 67025 (Injection of vitreous substitute, pars plana or limbal approach, [fluid-gas exchange], with or without aspiration [separate procedure]) and 67041 (Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane [e.g.,macular pucker]) are bundled by CCI; 67025 is bundled with 67041 as a more comprehensive bundle. You may not bill Medicare for both if performed on the same eye in the same session. If performed on different eyes, append modifier 59 to the second line item and RT (Right side) and LT (Left side) modifiers to indicate which eyewas involved for each procedure.

Do CCI Edits Only Apply to Part B?

Question 2: When we're billing a payer other than Medicare Part B, do we have to follow CCI edits, or are they Medicare-specific?

Answer: Although all Part B payers do follow the CCI edits, many other payers take them into account when determining which procedures should be paid separately.

Example: As part of the Affordable Care Act, state Medicaid programs were told to begin using CCI edits when processing claims as of Oct. 1, 2010. This means that you've probably seen CCI edits at work with some of your Medicaid claims. In addition, many private payers and workers' compensation insurers also use the CCI to justify claims payment and denials. You should check with your payers to determine which use the CCI edits and which do not.

Don't miss: Additionally, some private payers will not only use the CCI Edits to specify bundled services, but they may create additional edits not found in the CCI, says Mac. "Always check with your private payers to determine what services can be reported and paid, and periodically update your billing reference materials," she advises.

Don't Bill Patients When Exceeding MUE Limits

Question 3: We've had several claims denied due to themedically unnecessary edits (MUEs) that CCI has been instituting. We've been billing the balance to the patient but our auditor is trying to discourage us from continuingto do that. Why would that be?

Answer: You aren't alone in your belief that patients can be balance billed for this, but you join many other practices in believing this common MUE myth. The reality is that even if you have the patient sign an advance beneficiary notice (ABN), you cannot pass on the cost of procedures you know will be denied due to MUEs.

CMS makes this rule very clear in its FAQs (http://questions.cms.hhs.gov), stating: "A provider/supplier may not issue an ABN for units of service in excess of an MUE. Furthermore, if services are denied based on an MUE, an ABN cannot be used to shift liability and bill the beneficiary for the denied services. It is a provider/supplier liability."