Orthopedic Coding Alert

NCCI 13.1 deletes one edit but enacts several new ones

The National Correct Coding Initiative has unveiled its latest set of edits, which includes some good news for orthopedic surgeons who perform arthrotomy of the hip joint for biopsy during the same session as hip arthrotomy for drainage.

First, the Good News

Version 13.1 of the NCCI took effect April 1, and it includes 1,692 new edits. The new round of NCCI deletes 299 edit pairs, and 212 of those deletions were retroactive to the start of the year, says Frank Cohen with MIT Solutions Inc. in Clearwater, Fla. However, the one deletion that applies to orthopedic practices took effect March 31.

In the past, insurers would deny payment for 27030 (Arthrotomy, hip, with drainage [e.g., infection]) if you reported it with 27052 (Arthrotomy, with biopsy; hip joint). However, NCCI now deletes that edit, so you can report both codes together.

Keep in mind: The edit deletion doesn't mean you should bill these codes together if you don't have medical necessity. -In most cases, you-ll need two different ICD-9 codes -- one for the biopsy and another for the drainage,- says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

Modifier Changes and New Edits Abound for E/M Services

Modifier change: NCCI 13.1 also changes modifier indicators for another 132 edit pairs from -1- to -0,- meaning you can no longer override those edits with a modifier. These include edits bundling nursing facility/rest-home visit codes 99307-99310, 99324-99328 and 99334-99337 with observation codes 99218-99220 and 99234-99236.

In the past, if you had a good reason to bill these code pairs, you could use a modifier to explain why the services were separately identifiable and necessary. But now, Medicare has decided that you can never justify billing them together.

New E/M bundles: The NCCI also instituted new edits that bundle each new patient visit code from 99201-99205 with every lower-level code in the same series. You can't use a modifier to override those edits.

The same goes for initial observation codes 99218-99220, inpatient consultation codes 99251-99255, domiciliary/rest-home visit codes 99324-99337, and home visit codes 99341-99345.

Also, subsequent hospital care codes 99231-99233 are all bundled with initial inpatient service codes 99221-99223, and no modifier can override those edits, either. You also can't bill two different subsequent hospital visit codes for the same patient on the same day.

Possible rationale: Most coding experts agree that this follows Medicare's basic rule of bundling several E/M visits that occur on one day into one single E/M code. Coders really should not have been reporting multiple E/M codes -- especially from the same category -- together on the same date for the same patient, experts say.

NCCI Bundles Disc Arthroplasties, Osteotomies

When it comes to orthopedic codes, practices will have to update their billing software to reflect several new additions to the bundling edits.

You won't be able to bill the total disc arthroplasty codes 0090T-0096T with the spine osteotomy code 22220, arthrodesis code 22554, and cervical corpectomy code 63081. However, if your surgeon performs these as separate procedures, you can use a modifier (such as 59, Distinct procedural service) to override the edit.

Going in the other direction, NCCI will now bundle discography injection code 62291 and discography code 72285 into the 0090T-0096T series.

NCCI attacks 22857 series: Continuing with total disc arthroplasty, the NCCI instituted the following new edits that involve new codes 22857 (Total disc arthroplasty [artificial disc], anterior approach, including discectomy to prepare interspace [other than for decompression], lumbar, single interspace), 22862 (Revision including replacement of total disc arthroplasty [artificial disc] anterior approach, lumbar, single interspace) and 22865 (Removal of total disc arthroplasty [artificial disc], anterior approach, lumbar, single interspace):

 - NCCI now bundles 22857 into the osteotomy code 22224. 

 - You-ll now find osteotomy code 22224 bundled into both 22862 and 22865. 

 - All of the new total disc arthroplasty codes 22857-22865 are bundled into corpectomy codes 63087 and 63090. 

 - And the discography codes 62290 and 72295 are bundled into 22857-22865.

-The only way the new edits make sense to me is if the RVUs are raised to include the costs of the bundled codes,- says Susan Vogelberger, CPC, CPC-H, CMBS, owner and president of Healthcare Consulting and Coding Education in Boardman, Ohio. -Of course, you can bypass the edits if there is documentation of separate site, etc., by using modifier 59. Coders need to be diligent in checking the NCCI edits in order to bill these codes correctly.-