Practice Management Alert

When a payer blames claim denial on the Correct Coding Initiative (CCI) bundles, do you know what that means? If you don't understand what CCI edits are, how they work, and how they affect your claims, you're risking denials, fraud charges, and lost reimbursement.

Check out these top three frequently asked questions -- and expert answers -- to increase your CCI know-how.

Every quarter CCI puts out a list of code pairs that Medicare -- and many private payers -- follow when they reimburse physician practices. The CCI edits list pairs of CPT and HCPCS codes that payers will not pay on when you bill them together. Medicare and other payers apply these edits to services you bill for the same provider, for the same beneficiary, and on the same date of service.

"All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2)," explains Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, consultant with MJH Consulting in Denver. "Codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1, unless the edits permit the use of a modifier associated with CCI."

"The purpose of the NCCI edits is to prevent improper payment when incorrect code combinations are reported," CMS explains on its Web site. You can find the current listing of CCI edits, as well as the CCI policy manual, on the CMS Web site at www.cms.hhs.gov/NationalCorrectCodInitEd.

CMS updates the CCI edits every quarter, and you should always consult the most recent version when coding.

Important: If you bill for a hospital, keep in mind that hospital edits run one quarter behind physician CCI edits. "Pay special attention to the start/stop dates in the adjacent columns since CCI edits are 'date of service' sensitive," says Joan Gilhooly CPC, CHCC, president of Medical Business Resources LLC in Deer Park, Ill.

CCI edits include two types of edits: mutually exclusive and "column 1/column 2" (previously known as "comprehensive/component") edits.

Here's the difference: Mutually exclusive edits pair procedures or services that the physician could not reasonably perform at the same session on the same beneficiary. For example, CCI lists 60252 (Thyroidectomy, total or subtotal for malignancy; with limited neck dissection) as mutually exclusive of 60260 (Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid). The payer could not perform a total thyroidectomy and remove tissue following a previous removal of a portion of thyroid at the same session.

Column 1/column 2 edits describe "bundled"procedures. That is, CMS considers the code listed in column 2 included as a component of the more extensive column 1 procedure. For example, CCI bundles biopsy code 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) into lesion excision code 11403 (Excision, benign lesion including margins, except skin tag [unless listed else-where], trunk, arms or legs; excised diameter 2.1 to 3.0 cm).

The first column in the CCI Excel spreadsheet "generally represents the major procedure or service" and the code in the second spreadsheet column "often represents the component part," Hammer says. "However, within the mutually exclusive edits table, the column 2 code generally represents the procedure or service with the higher work (relative value unit [RVU]) and is the nonpayable procedure or service when reported with the column 1 code."

Payment woes: If you bill two mutually exclusive codes for the same patient during the same session, payers following CCI rules will reimburse only for the lesservalued of the two procedures. Conversely, if you billbundled (column 1/column 2) procedures for the same  patient during the same session, payers will pay you only for the higher-valued of the two procedures.

In certain clinical circumstances you can override -- not ignore -- CCI edits and receive separate reimbursement for bundled codes. To find out if you can separately bill services your physician performed, 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 reimbursement, such as a separate encounter on the same date, a separate anatomical site, or a separate indication.

Essential tip: Do not append a modifier to override a CCI bundle just to get paid or because you do not agree with a bundle. You can use a modifier to override a bundle only if your documentation supports using the modifier.

How it works: If you determine that the physician performed distinctly separate procedures, append modifier 59 (Distinct procedural service) to the code listed in column 2 of the CCI edits. Without modifier 59, the payer will simply apply the CCI edits and deny your claim. You should use modifier 59 to "indicate that there were special circumstances" that allow you to report the two codes together, Gilhooly explains.

Watch out: "CCI doesn't speak in terms of 'primary procedures,'" Gilhooly warns. "CCI uses the terms 'comprehensive' and 'component.'" You attach modifier 59 to the "component" code.

Note: Stay tuned to Medical Office Billing & Collections Alert for future articles about how and whenyou should use modifier 59.