Pediatric Coding Alert

Question:

If the codes are not listed in the CCI edits, the codes are not bundled under the Correct Coding Initiative (CCI) edit pairs. So most likely, you would not need a CCI modifier, such as 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), 57 (Decision for surgery), or 59 (Distinct procedural service), to override the edit when warranted.

However, a private payer could have a specific coding policy that precludes you from reporting certain codes together even if they aren't bundled according to CCI. You would need to check with a rep for a recommendation. In addition, the CCI Manual (www.cms.gov/NationalCorrectCodInitEd/) and CPT guidelines may offer broad instructions on types of services that generally should not be reported together. You also should be sure you check both nonmutually exclusive and mutually exclusive CCI edits.

Remember: Just because a code does not have a bundle in CCI does not mean a modifier is out of the picture. Even if you don't need a CCI modifier to override an edit, you might need a payment modifier for a code.

Coming up: Look for an article on new CCI changes that impact your pediatric practice in an upcoming issue of Pediatric Coding Alert.