Pathology/Lab Coding Alert

Missing modifier could mean missing legitimate lab test pay.

What do you have to lose if you don’t understand Correct Coding Initiative (CCI) edit lingo? How about procedure pay, fraud protection, and denial defense. Check out these top three frequently asked questions -- and expert answers -- to increase your CCI know-how.

1. What Is a CCI Edit?

Every quarter CCI puts out a list of code pairs that Medicare -- and many private payers -- follow when they pay for your lab and pathology services. The CCI edits list pairs of CPT and HCPCS codes that payers will not reimburse when you bill them together for the same patient on the same date of service.

“All edits consist of code pairs that are arranged in two columns -- column 1 and column 2,” says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, consultant with MJH Consulting in Denver. You won’t get paid for a column 2 code performed for the same patient on the same day as the associated column 1 code unless the edits permit you to use a modifier, Hammer explains.

Important: If you bill for a hospital, keep in mind that hospital edits run one quarter behind physician CCI edits. “Pay special attention to the start/stop dates in the adjacent columns since CCI edits are ‘date of service’ sensitive,” says Joan Gilhooly CPC, CHCC, president of Medical Business Resources LLC in Deer Park, Ill.

2. Why Are There 2 Edit Types?

CCI edits include two types of edits: mutually exclusive and “column 1/column 2” edits.

Here’s the difference: Mutually exclusive edits pair procedures or services that the physician could not reasonably perform using the same specimen collection for the same beneficiary. For example, CCI lists 81000 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy) as mutually exclusive of 81001 (… automated, with microscopy). The lab would not perform both an automated and non-automated urinalysis from the same patient specimen collection. Column 1/column 2 edits describe “bundled” procedures. The column 1 code generally represents the comprehensive service, and the column 2 code is the component that is part of the more extensive column 1 procedure.

Payment woes: If you bill two mutually exclusive codes for the same patient specimen on the same day, payers following CCI rules will pay only for the lesservalued of the two procedures. Conversely, if you bill bundled (column 1/column 2) procedures for the same patient specimen collection on the same day, payers will pay you only for the higher-valued of the two.

3. Can I Ever Ignore the Edits?

In certain clinical circumstances you can override -- not ignore -- CCI edits and receive separate payment for bundled codes. To find out if you can separately bill services, first check the “modifier indicator” in column F of the CCI spreadsheet.

A “0” indicator means that you cannot unbundle the two codes under any circumstances. An indicator of “1,” however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate payment, such as a medically necessary separate test collection on the same date or a separate specimen from a distinct anatomic site.

Tip: The most common modifier that labs use to override an edit pair is 59 (Distinct procedural service).

Resource: You can access the quarterly CCI edits at www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp.