Practice Management Alert

Most coding software programs incorporate the quarterly National Correct Coding Initiative (NCCI) edits but understanding the context around the how and why of each edit is crucial to deploying the affected codes correctly.

Here’s a game plan to boost your knowledge, avoid coding errors, and minimize claim rejections: Learn about the different edit types, the logic behind each edit, and the ways to work around the edits when circumstances demand. Keep reading to learn more.

Be Familiar with NCCI Edits

The NCCI edits are a national standard for ensuring proper payment and coding. Or, as CMS explains it, the purpose “is to prevent improper payment when incorrect code combinations are reported” by assembling “code pairs that should not be reported together for a number of reasons” (www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/).

“The goal [in creating NCCI] was to set a methodology that would identify unbundling and over-coding scenarios,” according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Define ‘Edit Pairs’

An edit pair consist of two codes listed in two columns (bundled), known as a procedure-to-procedure (PTP) edit pair. CMS creates a PTP edit pair for two situations:

• When CMS regards a specific service (Column 2 code) as being a component part of a larger, more comprehensive service (Column 1 code).
• When CMS deems that two services (codes) would never reasonably occur together (are mutually exclusive).

If you submit a claim with two bundled codes, the Column 1 code is eligible for payment, but Medicare will deny the Column 2 code unless both codes are clinically appropriate, adequately documented, and correctly reported using coding tools such as modifiers, which you’ll learn about later .

Key: “When talking with your surgeons about edits, clarify that it’s not that the bundled code isn’t a paid service, it’s that it is paid as part of the primary code, so reporting the service separately is attempting to be paid for it twice,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia. “The discussion around bundling is too often that the service is being done for free, and that is incorrect.” But when the second procedure is in a separate anatomical area, the appropriate modifier should allow for separate payment of that additional procedure.

Navigate Edits Like This

To understand when you might legitimately override an edit pair, CMS assigns each PTP edit pair one of three modifier indicators. An indicator of 0 means that you cannot unbundle the edit pair under any circumstances, and Medicare will pay only the Column 1 code on a claim featuring both services. An indicator of 1 means that you may report both services, when medically appropriate, if you append an NCCI-associated modifier to the Column 2 code. An indicator of 9 means the edit pair has been deleted.

Example: Code 19083 (Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance) is a Column 2 code to 19301 (Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)),

which means they are bundled together. However, since the modifier indicator for this PTP edit pair is 1, you may break the edit with an NCCI-associated modifier under certain circumstances, such as performing 19083 on the left breast and 19301 on the right breast.

Know the NCCI-Associated Modifiers

NCCI-associated modifiers “allow for certain CPT^® codes to be billed together when they are medically appropriate and when the documentation supports the allowance of both CPT^® codes,” explains Johnson.

Depending on the circumstances, you can use one of the following modifiers to unbundle an edit pair:

• Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
• Global surgery modifiers: 24, 25, 57, 58, 78, 79
• Distinct service modifiers: 59, 91, XE, XS, XP, XU.

Use NCCI-Associated Modifiers Like This

To select the appropriate modifier, you should have an in-depth knowledge of the procedure, the anatomy, and the timing of the service relative to other procedures.

“This is especially true when it comes to the proper use of modifier 59 (Distinct procedural service),” notes Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. Modifier 59 is probably the most utilized and well-known modifier when it comes to PTP edits. “However, it’s also a widely abused modifier that some may use just to bypass an edit, so make sure you only append this modifier if it best describes the circumstances,” says Arlene Dunphy, provider outreach and education consultant at the Medicare Administrative Contractor (MAC) National Government Services (NGS).

Key: You should never use 59 as the default modifier, because it does not provide information that might align with documentation, and it does not signal to payers why the provider is unbundling the codes.

That’s why Medicare and other payers are now instructing practices to replace -59 with the X{EPSU} modifiers, which further clarify the reason for unbundling the edit pair, as follows:

• XE (Separate encounter, a service that is distinct because it occurred during a separate encounter)
• XP (Separate practitioner, a service that is distinct because it was performed by a different practitioner)
• XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure)
• XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service)

Although Medicare generally encourages using an X{EPSU} modifier instead of 59, you should follow your specific payers’ instructions, but never submit both.

Medical record: Documentation is key when using modifiers to override an edit pair. The medical record must support the reason the two procedures should be unbundled and billed separately, such as “being performed on separate sites, at separate encounters, by different practitioners, or due to special circumstances, such as changing out endoscopes and then examining a different anatomic area because the two diagnostic endoscopies could not have been accomplished by a single endoscope,” explains Barbara J. Cobuzzi, MBA, CPC, COC, CPCO, CPC-P, CPC-I, CENTC, CMCS, of CRN Healthcare Solutions in Tinton Falls, New Jersey.