Podiatry Coding & Billing Alert

Get ready for CCI with tips from our pros.

Over 20 years ago, CMS created the Correct Coding Initiative (CCI) to promote correct coding and to reduce inaccurate payments. However, if you’ve ever searched through the CCI edits Excel sheet looking for answers about edit pairs, you know the task can seem daunting.

Read on to discover FAQs about how to interpret CCI edits and safeguard your podiatry practice.

FAQ 1: What are PTP edits?

Answer: In 1996, CMS implemented Procedure-to-Procedure (PTP) edits, which indicate the CPT^® and HCPCS code pairs you should normally not report together. CMS updates its PTP edits quarterly.

To better understand PTP edits, refer to the PTP code pairs in the table below. The code pairs contain both a Column 1 code, 28291 (Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant) and a Column 2 code.

In the example below, you also notice Column 2 codes 11044 (Debridement, bone [includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed]; first 20 sq cm or less)  and 11045 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; each additional 20 sq cm, or part thereof [List separately in addition to code for primary procedure]).

Based on this example, if you report both codes of a PTP pair for the same patient on the same date of service, the Column 1 code, 28291, is eligible for payment, but your payer will deny the Column 2 code — 11044 or 11045.

FAQ 2: What’s the significance of PTP modifier indicators?

Answer: Although PTP edits show which CPT^® codes you should not report together, you can append a modifier to override edits — under some circumstances. To learn whether overriding a particular edit is allowed, you will look in the modifier indicator column, which contains either a 0, 1, or 9.

Learn what the modifier indicators mean to ensure you append them appropriately:

• 0: You cannot use a modifier to override the edit under any circumstances.
• 1: You can use a modifier to override the edit when appropriate. Remember: The documentation and clinical circumstances must always support your decision to use the modifier. Examples include separate sites or sessions for the services. Never append a modifier just to bypass the edit.
• 9: The modifier indicator is irrelevant. The typical example involves CMS deleting an edit retroactively, meaning it’s as if the edit never existed.

Based on our example, 1 is the modifier indicator for the 28291/11044 and 28291/11045 edits, so you can override these edits under certain circumstances.

Learn more: Visit www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html and see the menu on the left side of the Web page to find the PTP edit tables. To read the helpful guidelines in the National Correct Coding Initiative Coding Policy Manual for Medicare Services, look under “Downloads” on the same Web page.

FAQ 3: How can I stay informed about CCI edits and protect my podiatry practice?

Answer: Check out tips from our experts to see how you can prep for each new release of the CCI edits.

Tip 1: Take time to review any edit changes and communicate findings with your practice.

Practices should have a point person to take the uninterrupted time to go over the changes and then share them with their staff, says Terry A. Fletcher, BS, CPC, CCC, CEMC, CCS-P, CCS, CMSCS, CMCS, CMC, ACS-CA, SCP-CA, healthcare coding educator, auditor, and management consultant of Terry Fletcher Consulting.

Tip 2: Get your info from dependable sources.

“I’m always compiling new information with supporting documentation before I change my coding practices/procedures,” says Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions, Coding Quality & Education Department. “I never immediately change the coding practices/procedures without three references supporting any guidance or changes.”

Tip 3: Always review the edits before you submit a claim.

“My advice is to always check the NCCI edits for each and every procedure reported,” says Dolly Perrine, CCS-P, CPC, CPC-I, CUC, CPMA, auditor and educator of professional services at St. Charles Health System in Bend, Ore. “When I coded services (now auditing), I would always (can I repeat it again, always) check the NCCI edits. Because (now I’m putting on my billing hat), I think you leave money on the table if you do not report procedures that can be ‘unbundled’ using a modifier.”

Tip 4: Documentation is the key to supporting an override.

“If documentation supports reporting both procedures (with modifier), and one procedure is denied, always appeal,” says Perrine. “I have found that if I have supporting documentation and the claim is denied due to bundling, if I appeal, it would most always be paid. I’m aware that it takes additional time to appeal, but once again, that’s money left on the table.”