Otolaryngology Coding Alert

Question: When can I unbundle CCI edits?

Georgia Subscriber

Answer: Each Correct Coding Initiative (CCI) code-pair edit includes a correct coding modifier indicator of 0 or 1.

A "0" indicator means that you may not unbundle the edit combination under any circumstances, according to CCI guidelines.

An indicator of "1," however, means that you may use a modifier to override the edit if the procedures are distinct from one another

You should only attempt to override CCI code pair edits if the paired procedures are separate and unrelated, however. For instance, the physician may have provided the services/procedures at different sessions or at different anatomic locations, such as left versus right, or cheek versus forehead.

Example: The ENT performs 31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) on the left side and 31254 (... with ethmoidectomy, partial [anterior]) on the right side.

CCI usually bundles 31254 to 31255, but includes a "1" indicator. In this case, because the ENT provided the services to visualize different areas for separate reasons, you should report both procedures. To support your coding, you should include an appropriate, documented diagnosis for each procedure.

Don't forget: In addition, you must append modifier 59 (Distinct procedural service) to the column 2 code to indicate to the payer that the billed procedures are distinct and separately identifiable.

In this example, you would report 31255 and 31254 with modifier 59 appended to clarify that the procedures occur at different anatomic sites.