Orthopedic Coding Alert

Question: The Correct Coding Initiatives (CCI) is an enigma to me; I have a lot of trouble with the terminology. For instance, what is the difference between mutually exclusive edits, and medically unlikely edits?

Michigan Subscriber

Answer: Though they may sound similar on the surface, CCI identifies them as completely different kinds of edits.

The Centers for Medicare and Medicaid Services (CMS) defines CCI Procedure-to-Procedure (PTP) code pair edits — Column 1 and Column 2 edits — as “automated prepayment edits that prevent improper payment when certain codes are submitted together.” In other words, the Column 2 code is a procedure that is a component part, or bundled into, the more comprehensive service described by the Column 1 code.

CCI provides three indicators for these edits:

• 0 (Not allowed): There are no modifiers associated with CCI that are allowed to be used with this PTP code pair; there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider.
• 1 (Allowed): The modifiers associated with CCI are allowed with this PTP code pair when appropriate.
• 9 (Not applicable): This indicator means that an CCI edit does not apply to this PTP code pair.

(Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf).

So, you can separate edits with a 1 indicator using modifiers such as modifier 59 (Distinct procedural service) in the case of procedures, modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service), in the case of evaluation and management (E/M) services, or Level II modifiers when procedures are distinct due to anatomical location.

But you cannot unbundle edits with a 0 identifier at all, and some of these are what are known as mutually exclusive edits, or procedures that cannot reasonably be expected to be performed at the same time. According to Medicare’s 2018 literature on CCI, “mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter. An example of a mutually exclusive situation is the repair of an organ that can be performed by two different methods.”

Medically unlikely edits (MUEs), however, are edits that exceed the maximum units of service that are allowed by a CPT^® or HCPCS code. As an example, a code such as 44970 (Laparoscopy, surgical, appendectomy) carries an MUE unit of 1 simply because it would be impossible to remove more than one appendix from one specific patient.