Pediatric Coding Alert

Tip: Be careful when separating bundled services.

If you don’t understand what Correct Coding Initiative (CCI) edits are, how they work, and how they affect your claims, you’re risking denials, fraud charges, and lost reimbursement.

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 reimburse physician practices. The CCI edits list pairs of CPT® and HCPCS codes that payers will not pay on when you bill them together. Medicare applies these edits to services you bill for the same provider, for the same beneficiary, on the same date of service.

All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2. Codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1, unless the edits permit the use of a modifier associated with CCI.

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.

2. Why Are There Two 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 at the same session on the same beneficiary. For example, CCI lists 60252 (Thyroidectomy, total or subtotal for malignancy; with limited neck dissection) as mutually exclusive of 60260 (Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid). The doctor could not perform a total thyroidectomy and remove tissue following a previous removal of a portion of thyroid at the same session.

Column 1/column 2 edits describe “bundled” procedures. CMS considers the code listed in column 2 included as a component of the more extensive column 1 procedure.

The first column in the CCI Excel spreadsheet generally represents the major procedure or service and the code in the second spreadsheet column often represents the component part. However, within the mutually exclusive edits table, the column 2 code generally represents the procedure or service with the higher work RVU and is the nonpayable procedure or service when reported with the column 1 code.

Payment woes: If you bill two mutually exclusive codes for the same patient during the same session, payers following CCI rules will reimburse only for the lesser-valued of the two procedures. Conversely, if you bill bundled (column 1/column 2) procedures for the same patient during the same session, 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 reimbursement for bundled codes. To find out if you can separately bill services your physician performed, first check the “modifier indicator” on 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 reimbursement, such as a separate encounter on the same date, a separate anatomical site, or a separate indication.

Tip: Do not append a modifier to override a CCI bundle just to get paid or because you do not agree with a bundle. You can use a modifier to override a bundle only if your documentation supports using the modifier.