Part B Insider (Multispecialty) Coding Alert

Use this primer to prepare for what’s ahead.

CMS initiated the Correct Coding Initiative (CCI) to promote better coding and reduce improper payments. Take a look at these fundamentals that help you clarify CCI edit pairs for cardiology.

Identify PTP Edits for Clarity

Fun fact: CCI edits are more than 20 years old. In 1996, CMS implemented Procedure-to-Procedure (PTP) edits. These edits indicate the CPT^® and HCPCS code pairs you should normally not report together. CMS updates its PTP edits quarterly. If you’ve been in the coding game a while, you may remember the days when CMS called these edits Column

One/Column Two edits and Mutually Exclusive edits.

As an example, refer to the PTP cardiology code pairs in the table below. You see that the code pairs contain both a Column 1 code, 92920 (Percutaneous transluminal coronary angioplasty; single major coronary artery or branch) in our example, and a Column 2 code.

In our example, edits you can see Column 2 codes 37246 (Transluminal balloon angioplasty [except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit], open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; initial artery) and +37247 (… each additional artery [List separately in addition to code for primary procedure]).

As per our example, if you report both codes of a PTP pair for the same patient on the same date of service, the Column 1 code, 92920, is eligible for payment, butyour payer will deny the Column 2 code — 37246 or +37247.

Understand PTP Modifier Indicators to Deepen Your Knowledge

Although PTP edits show which CPT^® codes you should not report together, under some circumstances, you can use a modifier to override the edits. To learn whether overriding the edit is allowed, you will look in the modifier indicator column, which contains 0, 1, or 9. Learn what the modifier indicators mean to ensure you use them correctly:

0: You cannot use a modifier to override the edit under any circumstances.

1: You can use a modifier to override the edit when appropriate. Remember: The documentation and clinical circumstances must always support your decision to use the modifier. Examples include separate sites or sessions for the services. Never append a modifier just to bypass the edit.

9: The modifier indicator is irrelevant. The typical example involves CMS deleting an edit retroactively, meaning it’s as if the edit never existed.

Based on our example, 1 is the modifier indicator for the 92920/37246 and 92920/+37247 edits, so you can override the edits under certain circumstances.

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. To read the helpful guidelines in the National Correct Coding Initiative Coding Policy Manual for Medicare Services, look under “Downloads” on the same Web page.

Get Up to Speed on CCI Edits to Protect Your Practice

Check out these helpful tips from our pros to learn how you can prepare for and apply each new release of the CCI edits.

Tip 1: Find reliable sources for your info.

“I’m always compiling new information with supporting documentation before I change my coding practices/procedures,” says Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions, Coding Quality & Education Department. “I never immediately change the coding practices/procedures without three references supporting any guidance or changes.”

Tip 2: Take time to review changes and communicate findings with your practice.

Practices should have a point person to take the uninterrupted time to go over the changes and then share them with the staff, says Terry A. Fletcher, BS, CPC, CCC, CEMC, CCS-P, CCS, CMSCS, CMCS, CMC, ACS-CA, SCP-CA, healthcare coding educator, auditor, and management consultant at Terry Fletcher Consulting.

Tip 3: Always review the edits before you submit a claim.

“My advice is to always check the NCCI edits for each and every procedure reported,” says Dolly Perrine, CCS-P, CPC, CPC-I, CUC, CPMA, auditor and educator of professional services at St. Charles Health System in Bend, Ore. “When I coded services (now auditing), I would always (can I repeat it again, always) check the NCCI edits. Because (now I’m putting on my billing hat), I think you leave money on the table if you do not report procedures that can be ‘unbundled’ using a modifier.”

Tip 4: Remember documentation is key to supporting override.

“If documentation supports reporting both procedures (with modifier), and one procedure is denied, always appeal,” says Perrine. “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.”

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