Outpatient Facility Coding Alert

Hint: Know your individual payers' policies.

The new Correct Coding Initiative (CCI) 24.0 edits are here and combing through the numerous edits may seem like a challenging task. Answer these CCI edits FAQs to ensure you are fully equipped with all the knowledge you need to ace these edits.

FAQ 1: How important is it to review the CCI edits before submitting a claim?

Answer: CCI edits are reviewed and revised on a quarterly basis, and this data is usually available several weeks before the start of a new quarter, according to Ruby Woodward, BSN, CPC, CPMA, CPB, COSC, CSFAC, CPC-I, coding and compliance manager at Suburban Imaging/Suburban Radiologic Consultants in Minneapolis, Minnesota.  

"I strongly recommend not relying on memory and always checking the edits when submitting claims for multiple services on the same [date of service] DOS," Woodward adds

Learn more: Visit www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html and see the menu on the left side of the Web page to find the PTP edit tables.

FAQ 2: What types of helpful resources are available to help with CCI edits?

Answer: Ongoing education through newsletters, periodicals, and reference books is also important for CCI edit success, says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, staff services coordinator/billing/credentialing/auditing/coding at County of Stanislaus Health Services Agency in Modesto, California.

"In addition, investing in good software or programs that will let you easily cross-check codes against each other is a huge time-saver," Johnson adds. "Becoming an expert in CCI edits will save your [facility] a ton of time and help with quicker reimbursements."

Editor's note: Stay tuned to Outpatient Facility Coding Alert for CCI info throughout the year. Codify also offers a tool, CCI Edits Checker, which makes checking your claim for CCI edit conflicts as efficient as possible - letting you see everything you need to know at a glance. This coder-designed tool makes it easy to download a PDF of your results and checks CCI edits for up to 25 codes at a time. Try a 14-day free trial here: https://www.aapc.com/codify/cci-edits.aspx.

FAQ 3: What is the importance of documentation in the case of an override?

Answer: "If documentation supports reporting both procedures (with modifier), and one procedure is denied, always appeal," says Dolly Perrine, CCS-P, CPC, CPC-I, CUC, CPMA, auditor and educator of professional services at St. Charles Health System in Bend, Oregon. "I have found that if I have supporting documentation and the claim is denied due to bundling, if I appeal, it would most always be paid. I'm aware that it takes additional time to appeal, but once again, that's money left on the table."

FAQ 4: What is the CCI Policy Manual for Medicare Services?

Answer: "In addition to the CCI edits, it is also important to read the CCI Policy Manual for Medicare Services," Woodward says. Instructions within the manual defining particular edits may not show up in the tables, so be aware of the information within the manual.

Updates to the manual happen annually, and those changes are noted in red, Woodward adds.

"I read through these changes annually," Woodward says. "Generally, I will print the manual, but I am also more of a paper than electronic person. I then read and highlight pertinent information. I also have the manual bookmarked for easy access when I need it. For some edits, I will make a notation in my coding manuals, which may simply be 'to check CCI.'"

You can find the manual at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html as the last file under "Downloads."

FAQ 5: Why should we learn individual payers' policies?

Answer: Remember that the CCI edits were created for Medicare and most government payers, Woodward says. So, it is important to know how your commercial payers utilize these edits - if at all.

"Do they follow the full edit, meaning the guidelines and the tables, or just the tables? Do they also follow the specialty societies global policies if they exist?" Woodward says. "If CCI says the services are bundled with an indicator of 1, but the specialty society says the procedure is not inclusive, will the health plan honor the specialty society and the use of the 59 or other appropriate modifier?"

FAQ 6: What should I do if I feel overwhelmed with the CCI edits?

Answer: "Don't be intimidated," says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, manager of clinical compliance with PeaceHealth in Vancouver, Washington. "There are thousands of edits, but many of them are common sense, and many others will not apply to youbecause the services involved are not performed by providers you work with."

When you start coding a new procedure or service, take a look at the edits and also look for any [local coverage determinations] LCDs or [national coverage determinations] NCDs, and that will probably be enough to help you manage CCI edits well, Bucknam adds.

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