Outpatient Facility Coding Alert

Question: We’ve begun receiving denials when reporting 36478 with 36471. I found the Centers for Medicare & Medicaid Services (CMS) introduced a new National Correct Coding Initiative (NCCI) edit that bundles these codes with a modifier “1” indicator. Can I still report them separately?

Indiana Subscriber

Answer: You are correct that as of October 1, 2019, a new NCCI procedure-to-procedure (PTP) edit exists between codes 36478 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated) and 36471 (Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg).

Furthermore, the CCI edit rule justifies the edit as a “Misuse of column two code with column one code.” In order to understand whether you may override this edit with modifiers 59 (Distinct Procedural Service) and XS (Separate Structure…) or LT (Left Side) and RT (Right Side), you need to understand exactly what this NCCI edit rule means. CMS offers an in-depth explanation of what code edit scenarios warrant this NCCI rule in the Correspondence Language Manual for Medicare Services.

CMS explains that when two procedures are paired with the edit rule “Misuse of column two code with column one code,” you may only report the two respective services separately when the physician performs each on separate anatomic areas. When performed on the same site, CMS has flagged these services as being redundant.

With respect to codes 36478 and 36471, a bundling edit makes sense if the physician opts to perform both services on the same vein. In the case that the physician performs both 36478 and 36471 on the same vein of the same leg, you should not use an overriding modifier. When performed on the same or different veins on opposite legs, you may override the edit using laterality modifiers LT and RT. Finally, when the physician performs each service on different veins of the same leg, you may override the edit using modifier 59 (or XS for Medicare Part B patients) on the column 2 code, 36471. 

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