Orthopedic Coding Alert

HCFA has temporarily suspended many of the edits in version 6.3 of the national Correct Coding Initiative (CCI). These edits bundled more than 800 procedural codes with evaluation and management (E/M) codes, taking the coding world by surprise when they were issued last fall. The suspension, issued Jan. 26, is retroactive to Oct. 30, the date the 6.3 edits were issued.

The bundling of the E/M codes with diagnostic and radiological procedures required coders to use modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) when the E/M service represented a separate and significant service. HCFA plans to focus on educating physicians and coders as to what separate and significant service means.

Although the version 6.3 edits had little impact on orthopedic coders, orthopedists who submitted claims that were rejected due to the edits should revisit these. If modifier -25 applies, resubmit the claims. Correct coding dictates that you cannot bill for a service that was not performed. Modifier -25, when appended to an E/M code, is defined as representing a significant and separately identifiable service from another service or procedure.

The temporary suspension means only that HCFA is giving you a chance to look at your claims again. Before using modifier -25, make sure the service is significant and separately identifiable from the procedure. HCFA is reviewing the edits, and may reimplement many of them as early as July 1, 2001.

The HCFA memo Program Memorandum B-01-09 went into effect on Feb. 12, 2001, and with the exception of some ophthalmology codes, does not impact any of the more recent CCI version 7.0 edits. The complete program memorandum can be found at www.hcfa.gov/pubforms/ transmit/B0109.pdf.