Pediatric Coding Alert

Know why modifiers are your friend when dealing with CCI bundles

Many readers who wrote to Pediatric Coding Alert about the recent denials they faced when reporting vaccines with well child visits (see page 17 for details) were confused about why CCI edits impact them at all.

For many years, the perception was that these bundles only affected practices that billed Medicare. However, seven states used CCI edits on their Medicaid claims by 2003, based on a 2004 OIG report, and the remaining states were required to begin using CCI edits as of April 1, 2011 as part of the Affordable Care Act.

The following facts will help you when navigating CCI bundles.

There are two types of edits. CCI includes two different 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.

You must prove ‘separately identifiable services’ to override CCI 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.

Certain modifiers help you override edits: 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 or other qualified healthcare professional 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.