Otolaryngology Coding Alert

Question: When specialty-society guidelines differ from National Correct Coding Initiative (NCCI) edits, a commercial payer said we have to defer to the CMS bundles. Our contract does not stipulate that we must follow NCCI edits. The representative claims that because we are following society guidelines, we are -unbundling.-

We follow NCCI for Medicare, Tricare and Medicaid. When billing commercial payers, do we have to follow NCCI edits or CMS guidelines?


Virginia Subscriber
Answer: Many coding experts recommend that you code uniformly, meaning that you follow CMS guidelines and NCCI edits for all payers. Universal coding keeps you HIPAA-compliant and protects you from accusations of coding for payment.

Some coders still prefer to code per payer. 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 AAO-HNS and/or the specialty society and the payer to alert them to the inappropriate edit. Before reporting two bundled codes, make sure documentation justifies billing them separately.