Otolaryngology Coding Alert

Question: When specialty-society guidelines differ from National Correct Coding Initiative (CCI) edits, a commercial payer said we have to defer to the CMS bundles. Our contract does not stipulate that we must follow CCI edits. The representative claims that because we are following society guidelines, we are -unbundling.- We follow CCI for Medicare, Tricare and Medicaid. When billing commercial payers, do we have to follow CCI edits or CMS guidelines?


Virginia Subscriber


Answer: Many coding experts recommend that you code uniformly, meaning that you follow CMS guidelines and CCI edits for all payers. Universal coding keeps you HIPAA-compliant and protects you from accusations of coding for payment. Because payers do not use the same claim edits, some coders prefer to code per insurer. These practices either employ large billing staff who can focus on various regulations or are small and handle a low volume allowing this specificity. If the edits contradict specialty-society guidelines, you should work with the society--such as the American Academy of Allergy, Asthma and Immunology; the American College of Allergy, Asthma and Immunology; or the Joint Council of Allergy, Asthma and Immunology--and the payer to alert them to the inappropriate edit. Before reporting two bundled codes, make sure documentation justifies billing them separately.