Pathology/Lab Coding Alert

Learn when modifiers, ABNs won’t help your bottom line.

There’s more to Medicare’s Correct Coding Initiative (CCI) than just quarterly updates. Although you must keep abreast of the “edit pair” changes four times a year, you need to know other program facts if you want to avoid pitfalls and seize opportunities for your lab.

Use the following five frequentlyasked questions about CCI to help you focus your bundling/unbundling skills for clean claims and maximum correct pay.

FAQ 1: Merge Edit Tables

Question: I’ve heard there are two CCI edit tables. What’s the difference, and how can I be sure I’m seeing edits from both tables?

Answer: You’re correct that CCI had two edit tables — one for “Mutually Exclusive” edits and one for “Column 1/Column 2” edits — but no longer. Beginning April 1, 2012, CMS merged the two tables into a single paired-code edit table.

Now, if you go to the CCI Website (www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html), you don’t have to download and research two separate tables to look for a code pair in a specific numeric range. According to CMS, “all active and deleted edits [now] appear in the single Column One/Column Two Correct Coding edit file.”

Don’t miss: “The edits previously contained in the Mutually Exclusive edit file are NOT being deleted but are being moved to the Column One/Column Two Correct Coding edit file,” CMS states.

FAQ 2: Refine Your Modifier Skills

Question 1:Our billing company says that we can never bill together 88329 (Pathology consultation during surgery) and 88331 (… cytologic examination [e.g., touch prep, squash prep]), initial site) because doing so would be ignoring a CCI edit. Is this correct?

Answer:In certain clinical circumstances you can override — not ignore — some CCI edits and receive separate payment for bundled codes, such as 88329 and 88331.

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, says Chandra L. Hines, practice supervisor of Wake Specialty Physicians in Raleigh, NC. An indicator of “1,” however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate payment, she adds.

Tip:The most common modifier that labs and pathology practices use to override an edit pair is 59 (Distinct procedural service). But you should only use the modifier under specific clinical circumstances, such as two different specimens, lesions, anatomic sites, or tests for separate medical conditions.

Codes 88329 and 88333 serve as a good example. If the pathologist performs an intraoperative gross-only consultation on a tumor, and later performs a frozen section exam for a specific lymph node, you can bill both codes and append modifier 59 to 88329. But a gross inspection is an integral part of any microscopic exam, so billing 88329 and 88333 for a single frozen section intraoperative consult would constitute inappropriate “unbundling.”

FAQ 3: Distinguish CCI vs. CPT® ‘Separate Procedure’

Question: Our pathologist may perform flow cytometry and an immunohistochemistry (IHC) stain on a single bone marrow specimen. Because the work involves two distinctly separate procedures, interpretations, and CPT^®codes, can we bill them together?

Answer: Although CPT^®identifies flow cytometry (88184-88189, Flow cytometry …) and IHC (88342, Immunohistochemistry [including tissue immunoperoxidase], each antibody) as separate procedures that a pathologist may perform on a single specimen, Medicare (via CCI) states that the tests provide redundant diagnostic information. Based on CCI edits, you should bill these codes together only if the tests are for different medical conditions, or if the first method is non-diagnostic. Other payers may not follow this Medicare rule.

Similarly, CPT^®identifies different non-gyn cytology (88104-88112, Cytopathology, … except cervical or vaginal …) methods that represent separate procedures, but CCI considers the tests redundant and instructs labs to report “only one code from a group of related codes describing a group of services that could be performed on the specimen with the same end result (e.g., 88104-88112).

FAQ 4: Check Payers

Question:When we’re billing a payer other than Medicare Part B, do we have to follow CCI edits, or are they Medicare-specific?

Answer:Although all Medicare Part B payers follow the CCI edits, many other payers take them into account when determining which procedures should be paid separately, Hines says.

Example:As part of the Affordable Care Act, state Medicaid programs were told to begin using CCI edits when processing claims as of Oct. 1, 2010. This means that you’ve probably seen CCI edits at work with some of your Medicaid claims. In addition, many private payers and workers’ compensation insurers also use the CCI to justify claims payment and denials. You should check with your payers to determine which use the CCI edits and which do not.

FAQ 5: Save Your ABNs

Question: What’s the difference between a “medically unlikely edit” and a “CCI edit?” When we know that a charge will be denied due to these edits, can we get a signed an advance beneficiary notification (ABN) and bill the patient?

Answer:CCI edits relate to code pairings (whether two codes can be billed together), says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. MUEs refer to a single code and limit the number of times on a date of service that you can bill a particular code, she adds.

Regarding ABNs, the answer is, no, you shouldn’t balance bill a patient when you bill two codes together and one is denied because the codes are bundled by CCI edits. Because CMS considers the two bundled procedures not medically necessary, you can’t pass the cost on to the patient.

The same is true for MUEs. Even if you have the patient sign an ABN, you cannot pass on the cost of procedures you know will be denied due to MUEs, Cobuzzi warns.

CMS makes this rule very clear in its FAQs, stating: “A provider/supplier may not issue an ABN for units of service in excess of an MUE. Furthermore, if services are denied based on an MUE, an ABN cannot be used to shift liability and bill the beneficiary for the denied services. It is a provider/ supplier liability.”