Pain Management Coding Alert

Getting denials for new sedation codes? This could be why.

On January 1, the latest Correct Coding Initiative (CCI) went into effect. There is one major change — and one bundling error — in the first edit batch of 2017.

The news: CCI tightened up its rules on reporting certain services along with trigger point injections (TPIs). Also, Medicare found an error in their new coding bundles that they will correct with the second-quarter CCI edits in 2017.

Check out this rundown on the latest CCI news, and how it might affect your practice’s coding.

CCI Bundles TPI into 30-Plus Codes

One of the more vital bundles to observe is the edits involving trigger point injections (TPIs). When your provider performs TPI with another service, you’ll definitely be able to report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) or 20553 (… single or multiple trigger point[s], 3 or more muscle[s]), depending on the encounter specifics.

Caveat: Be careful coding the second service, though; the TPI codes are now Column 1 components of an edit set that includes more than two dozen services. When your provider performs TPIs with these services, the second service is considered a Column 2 code, and thus part of the work units of the TPI code.

You can check out the entire CCI list online, but some of the codes that CCI now bundles into 20552 and 20553 are:

• 0216T,  Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level
• 64400, Injection, anesthetic agent; trigeminal nerve, any division or branch
• 64510, Injection, anesthetic agent; stellate ganglion (cervical sympathetic)
• 99155, Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age.

Impact: “Providers and coders need to remain acutely aware of CCI edits, and monitor these edits on a regular basis to stay abreast of changes,” reminds Amy Turner,  RN, BSN, MMHC, CPC, Director of Revenue Integrity at Comprehensive Pain Specialists in Brentwood, Tenn. A lack of current CCI edit knowledge could clog up your payment cycle, Turner continues.

Remember: Each of these edits will have a modifier indicator of 0 or 1. If the edit’s modifier indicator is 0, you can never unbundle the services under any circumstances. You might be able to bypass the CCI edit if it has a modifier indicator of 1; if you can unbundle the codes, you’ll likely have to append modifier 59 (Distinct procedural service), or the appropriate X modifier, to the Column 2 code to ensure a successful claim.

For a complete list of the January 2017 CCI edits, go to: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/.

NGS Points Out Sedation Error

Also, remember those new moderate sedation codes in CPT^® 2017? Well, Medicare recently announced that CCI bundled some of those sedation codes in error.

The codes: Not all of the new sedation codes were affected by the erroneous bundle; the sedation codes at the heart of the announcement are:

• 99151, Moderate sedation services provided by the same physician or other qualified health care profes­sional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age
• 99152, … patient age 5 years or older
• 99153, … each additional 15 minutes intraservice time (List separately in addition to code for primary service).

National Government Services (NGS), a major Medicare carrier in the Midwest, announced the error in a late-January press release.

Referencing the January CCI edits, NGS reported that a CCI contractor advised them of an error in the new bundles. The 99151-99153 codes “were incorrectly bundled into seventeen global surgical procedures and sixteen Category III codes. These edits do not allow bypass with … modifiers (modifier indicator of ‘0’),” NGS reports.

The codes impacted by this issue that might be relevant to your practice are:

• 0424T, Insertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator) 
• 0425T, … sensing lead only
• 0426T, … stimulation lead only
• 0427T, … pulse generator only
• 0428T, Removal of neurostimulator system for treatment of central sleep apnea; pulse generator only
• 0429T, … sensing lead only
• 0430T, … stimulation lead only
• 0431T, Removal and replacement of neurostimulator system for treatment of central sleep apnea, pulse generator only 
• 0432T, Repositioning of neurostimulator system for treatment of central sleep apnea; stimulation lead only
• 0433T, … sensing lead only
• 0434T, Interrogation device evaluation implanted neurostimulator pulse generator system for central sleep apnea
• 0435T, Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; single session
• 0436T, … during sleep study.

CCI will correct these errors in the April 2017 CCI updates, NGS reports.

Best bet: CCI recommends providers delay submission of claims for 99151-99153 when the physician provides sedation along with one of the aforementioned codes. If you submit a claim before April 1 with 99151-99153 and one of the improperly bundled codes, the provider will still deny it. You can appeal any and all erroneous denials for 99151-99153 claims on or after April 1, NGS confirms.