Pediatric Coding Alert

You now have clear-cut policies to apply, including 1 on 96110 pay.

Say goodbye to secret black box bundles and hello to transparent CCI edits for one more insurer.

Adhere to CCI Edits, CMS Modifier Guidelines

Effective April 20, CIGNA will apply CMS National Correct Coding Initiative (NCCI) Incidental and Mutually Exclusive edits, according to the payers March 2009 Network News. The change puts the insurers policy on a level playing field.

For years, CIGNA did their own thing, points out Patti DiSpazio, CPC, business manager at Island Coast Pediatrics in Fort Myers, Fla. Following UHCs change, theyre using CCI edits as a barometer.

In addition, the payer will adopt many CMS modifier guidelines. Modifier policies being updated are Modifiers 21, 22, 25, 59, 80, 81, 82 and AS, CIGNA says.

Follow Up With Notes for Certain Combos

Get ready to have your modifier 25 (CCI incidental edits) and modifier 59 use (mutually exclusive edits) subject to increased scrutiny. Due to overuse of modifiers 25 (Significant, separately identifiable evaluation and management service on the same day of a procedure or other service) and 59 (Distinct procedural service), some code sets involving these modifiers will require supporting documentation. In these cases, such as an E/M with a surgery code, documentation must show the E/M is significant and separate.

Modifier 25 office visit (99201-99215, Office or Other Outpatient Services) claims with a preventive medicine service (99381-99397) will not require additional paperwork.But for code combinations listed on CIGNAs Web site starting May 1, you will have to mail documentation to the CIGNA address on the back of the patients ID card as the insurer cannot accept electronic attachments,according to the payers FAQs.

Time-saver: You can continue to file the claim electronically. Make sure you check the box in item 19 to indicate you are sending supporting documentation.

Make Sure Your Modifier Policies Are Up-to-Date

CIGNAs directive echoes CPTs modifier instructions.A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported, according to modifier 25s definition in Appendix A Modifiers. CPT 2008 added that modifier 59 documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of extensive injuries) not ordinarily encountered or performed on the same day by the same individual.

CMS adopted modifier 59s revised language that also limits the appendages use to between two procedures. Strict interpretation of modifier 59s language prevents it from being used to identify any same-day [non-E/M] service or procedure performed with an E/M service,reports Debra Pierce, MD, MBA, CPC, with Pierce MD Consulting in Rockbridge, Ohio.

Dont miss: Youll need to use one of these modifiers when reporting 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) and 99381-99397 (Preventive Medicine Services). Without a modifier, the developmental test code denies as incidental to the preventive medicine service, DiSpazio reports.

CIGNA will pay 96110 when you append modifier 25 to the 99381-99397, states the insurers developmental testing policy noted in the April 13 updated Professional Claims Code Editing and Documentation Requirements Guidelines. Alternatively, Modifier 59 may be appended to 96110 to indicate a distinct procedural service, if appropriate, according to the policy, which you can find via the payers secure Web site:  www.cignaforhcp.com.