Otolaryngology Coding Alert

Here’s how to use PTP edit pair know-how to fine-tune your procedural coding.

Although your coding software may seamlessly implement the quarterly National Correct Coding Initiative (NCCI) edits, you may face a denial without knowing why — unless you know how NCCI Procedure-to-Procedure (PTP) edits work.

If you’ve ever been stumped when trying to interpret the most recent NCCI update or wondered why the Centers for Medicare & Medicaid Services (CMS) produces this comprehensive listing, this one’s for you. We put together this FAQ in an attempt to answer those questions and help you use this valuable tool to improve your CPT^® coding accuracy.

What Are NCCI PTP Edits?

The NCCI edits are “a national standard for ensuring proper payment and coding. The goal was to set a methodology that would identify unbundling and over-coding scenarios,” according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Or, as CMS explains it, the purpose “is to prevent improper payment when incorrect code combinations are reported” by assembling “code pairs that should not be reported together for a number of reasons” (www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/).

What Are Edit Pairs?

CMS creates an edit pair when it regards a specific service as being a component part of a larger, more comprehensive service. When you submit two bundled codes, the Column 1 code is eligible for payment, but Medicare will deny the Column 2 code unless both codes are clinically appropriate, according to Arlene Dunphy, provider outreach and education consultant at the Medicare Administrative Contractor (MAC) National Government Services (NGS). Also, your provider must include supporting documentation in the medical record.

What Is an MUE?

In addition to PTP edit pairs, “CMS has created Medically Unlikely Edits, or MUEs, to reduce coding errors and fraud,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “MUEs represent the maximum number of times one service can be performed on one patient and are usually determined by such biological factors as how many organs or limbs typically exist in the human anatomy, or whether the service is gender specific. They are CMS’ way of deciding how many units you can bill on one service line,” Falbo further elaborates.

How Do the Edits Work?

CMS assigns Column 1 status to the comprehensive service and Column 2 status to a code they regard as being a component part of the Column 1 service.

Each PTP edit pair is then assigned one of three modifier indicators. An indicator of 0 means that the pair cannot be unbundled with an NCCI-associated modifier and that only Column 1 procedures will be paid in claims featuring both services. An indicator of 1 means that both services may be reported together if an NCCI-associated modifier is appended to the Column 2 code and both services are eligible for payment. An indicator of 9 means the pair has been deleted, and that you can ignore the indicator.

Example: Code 69421 (Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia) is a Column 2 code to 69436 (Tympanostomy (requiring insertion of ventilating tube), general anesthesia), which means they are bundled together. However, since the modifier indicator for this PTP edit pair is 1, you may break the edit with an NCCI-associated modifier under certain circumstances, such as performing 69421 on the left ear and 69436 on the right ear.

What Are NCCI-Associated Modifiers?

NCCI-associated modifiers “allow for certain CPT^® codes to be billed together when they are medically appropriate and when the documentation supports the allowance of both CPT^® codes. Normally, the CPT^® codes would be considered inclusive and denied as unbundled,” explains Johnson.

Depending on the circumstances, you can use one of the following modifiers to unbundle an edit pair:

Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI Global surgery modifiers: 24, 25, 57, 58, 78, 79 Other modifiers: 27, 59, 91, XE, XS, XP, XU.

Append NCCI-Associated Modifiers Appropriately

“You should have an in-depth knowledge of the procedure as well as anatomy to know when an NCCI-associated modifier should be allowed,” suggests Johnson. “This is especially true when it comes to the proper use of modifier 59 [Distinct procedural service],” notes Falbo.

Modifier 59 is probably the most utilized and well-known modifier when it comes to PTP edits. “However, it’s also a widely abused modifier that some may use just to bypass an edit, so make sure you only append this modifier if it best describes the circumstances,” Dunphy advises. You should never use modifier 59 as a default modifier.

Why? With the 59 modifier, payers cannot determine why the provider is unbundling the two codes and how they are supported in the documentation. That’s why Medicare and other payers are now instructing practices to replace -59 with the X{EPSU} modifiers, which further clarify the reason for unbundling the edit pair.

X{EPSU} modifiers: Modifiers XE (Separate encounter…), XP (Separate practitioner…), XS (Separate structure …), and XU (Unusual non-overlapping service …) are a subset of modifier 59 and may be used instead of -59. Whether you report an X{EPSU} modifier or modifier 59 on your claim will depend on payer preference; never submit both.

Also, documentation is key when using modifiers. The medical record must support the reason the two procedures should be unbundled and billed separately — “being performed on separate sites, at separate encounters, by different practitioners, or due to special circumstances, such as changing out endoscopes and then examining a different anatomic area because the two diagnostic endoscopies could not have been accomplished by a single endoscope,” explains Barbara J. Cobuzzi, MBA, CPC, COC, CPCO, CPC-P, CPC-I, CENTC, CMCS, of CRN Healthcare Solutions in Tinton Falls, New Jersey.

Red flag: If your payer prefers the X{EPSU} modifiers, do not use -59. Doing so tells the payer that you do not understand why you’re unbundling the CPT^® codes, which increases the chances of the claim being audited.