Ophthalmology and Optometry Coding Alert

Plus: You can also override bundles with modifiers LM and RI

We’ve all heard the old coding adage: If the CCI edit indicator is "1," you can separate the bundle using modifier 59 "or another suitable modifier," but many coders have been confused about what other modifiers apply to these instances.

CMS now adds to the list of applicable modifiers, with the introduction of four more modifiers that Medicare contactors will accept to bypass CCI edits.

Background: When a CCI coding combination is listed as either a mutually exclusive or comprehensive/component edit, the general rule is that both codes cannot be reported separately. However, two CCI indicators are commonly used to indicate when you can, in fact, report the procedures together under circumstances.

An indicator of "0" indicates that it is never acceptable to bill these procedures together, and an indicator of "1" indicates that these codes are considered bundled but can be billed separately under certain circumstances, such as a separate site, separate incision, or separate injury.

Most coders who are trying to separate CCI edits will use either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for edits involving E/M codes, or modifier 59 (Distinct procedural service) for bundles that involve two procedures.

However, coding experts have long maintained that modifier 59 should be the modifier "of last resort," making many coders reluctant to use it extensively.

Help Is Here

CMS Transmittal 1136, released on Nov. 1, announces that you’ll be able to use the following modifiers to override a CCI edit with a modifier of "1" effective Jan. 1, 2013:

• LM (Left main coronary artery)
• RI (Ramus intermedius)
• 24 (Unrelated evaluation and management service by the same physician during a postoperative period)
• 57 (Decision for surgery)

Whereas modifiers LM and RI will mainly be used by heart surgeons, the other two modifiers are quite familiar to most other coders. Both modifiers 24 and 57 can be appended to E/M codes when the E/M service is either unrelated to a surgery (modifier 24) or results in the decision to perform the bundled procedure (modifier 57).

Resource: To read the complete Transmittal, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1136OTN.pdf.