Optometry Coding & Billing Alert

Question: We sometimes get denials that appear to be related to bundling issues but I can't find the two-code pair in the CCI edits. How can I find out which is the column 2 code so that I can put the modifier on the correct code?

Answer: If you can't find the codes listed in the Correct Coding Initiative (CCI) edit tables, then they're not bundled under that system. Make sure you check both the mutually exclusive and non-mutually exclusive edit tables.

If your code pair is not bundled under CCI, then you would not need a CCI modifier such as 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), 57 (Decision for surgery), or 59 (Distinct procedural service), to override the edit pair.

Watch out: Just because a code does not have a bundle in CCI does not mean a modifier is out of the picture. While you won't need a CCI modifier to override the edit, you might need a payment modifier.

You can find Medicare's other allowed modifiers for any given CPT code in the Medicare Physician fee schedule (MPFS). Columns Y-AC indicate if a modifier such as 50 (Bilateral  procedure), etc. applies. This info is also in Codify's fee schedule information (https://www.aapc.com/codify/medicare-fee-schedules.aspx)