Pediatric Coding Alert

Know where to find Correct Coding Initiative edits to ensure you're coding properly.

If you've always felt like the terms "CCI," and "Correct Coding Initiative" didn't apply to your practice because you don't deal with Medicare patients, that time has unfortunately passed. State Medicaid payers will now be denying claims based on CCI edits, and you need to know how to continue to collect your due despite these hurdles.

Because some private insurers follow Medicare's lead regarding claims processing, some of your contracted payers may already be using CCI edits to "bundle" or deny claims for services you rendered. However, if you've never encountered these edits before, it's time to find out the basics to avoid facing unnecessary Medicaid denials.

Here's why: As part of the Affordable Care Act, which President Obama signed into law last March, state Medicaid programs were told to begin using CCI edits when processing claims as of Oct. 1, 2010. This means that you may find some unexpected denials due to bundling edits on Medicaid claims submitted with dates of service on or after Oct. 1.

The following information will give you the lowdown on CCI edits and how they'll affect your Medicaid reimbursement.

1. What Is a CCI Edit?

Every quarter, CCI puts out a list of code pairs that Medicaid will follow when paying for your pediatric 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.

Resource: You can access the quarterly CCI edits at www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp. Look to Pediatric Coding Alert every quarter starting in 2011 to find out which new code pairs will impact your practice.

The 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.

For instance: Suppose a nurse provides nebulizer education/demonstration/monitoring for a patient after administering a nebulizer treatment. You would appropriately report 94664 (Demonstration and/ or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) as well as 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device).

The CCI, however, bundles 94664 into 94640, so without a modifier, Medicaid will pay you for 94640 but not for 94664 (more on modifiers below).

2. Why Are There Two Edit Types?

CCI includes 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 together. For example, a pediatrician may not report both 99222 (Initial hospital care) and 99238 (Hospital discharge) on the same date for the same patient.

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.

Tip: The most common modifiers that pediatric practices use to override an edit pair are 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when used with an associated E/M code, or modifier 59 (Distinct procedural service) when two non-E/M services are performed, but other modifiers may apply in some circumstances.

For instance: In our example above, you learned that the CCI edits bundle 94664 into inhalation treatment code 94640. CCI, however, allows you to report a modifier to override this bundle when circumstances make separately reporting the education appropriate. For Medicaid and payers that follow the edits, if the education occurs while the patient is receiving the inhalation treatment, do not separately bill the education. However, if, for example, the pediatrician provides the inhalation treatment and subsequently performs the training, you may report 94664 with modifier 59 (Distinct procedural service).

4. State Rules Are Paramount

Individual state Medicaid programs are entitled to institute additional edits if they choose, the CMS Web site indicates. Therefore, any CCI edits listed on your state Medicaid Web site may trump those found on the main CMS Web site.

For more on CCI edits and how they impact your Medicaid pay, visit www.cms.gov/MedicaidNCCICoding/.