Practice Management Alert

Bad news: Modifier 59 can't help on many of the new edits


Heads up: The National Correct Coding Initiative (NCCI) has unveiled its latest set of edits, many of which affect urology, neurosurgery, and pathology and laboratory codes. Version 13.1 took effect April 1, and it includes 1,692 new edits. Resubmit Cysto and Craniectomy Claims  Deletions: NCCI 13.1 deletes 299 edit pairs, and 212 of those deletions were retroactive to the start of the year, says Frank Cohen with MIT Solutions Inc. in Clearwater, Fla. That means if you received denials for any of these code pairs since Jan. 1, you can resubmit those claims and get paid.
 
What to do: You can resubmit any denied claims for cystourethro-scopy code 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) along with a dozen other cystourethroscopy codes, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.
 
Also, NCCI 13.1 deletes edits bundling six craniectomy/craniotomy codes with stereotactic body radiation-therapy code 77373 (Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions). It also deletes edits bundling a few dozen nervous-system surgery codes with stereotactic body radiation-treatment codes 77371-77373.
 
Lab bonus: You won't have to worry about 64 pathology and lab testing codes being bundled with tissue-culture code 87253 (Virus isolation; tissue culture, additional studies or definitive identification [e.g., hemabsorption, neutralization, immunofluorescence stain], each isolate). Seven of those path and lab testing codes will also be unbundled from centrifuge-enhanced virus isolation code 87254 (Virus isolation; centrifuge enhanced [shell vial] technique, includes identification with immunofluorescence stain, each virus). Watch Out for Modifier Indicator Changes  The latest round of NCCI edits also changes modifier indicators for another 132 edit pairs from -1- to -0,- meaning you can no longer override those edits with a modifier.
 
These include edits bundling laparoscopic enterolysis code 44180 (Laparoscopy, surgical, enterolysis [freeing of intestinal adhesion] [separate procedure]) with some surgical codes; surgical anorectal exam code 45990 (Anorectal exam, surgical, requiring anesthesia [general, spinal, or epidural], diagnostic) with a host of digestive-system surgery codes; pelvic exam code 57410 (Pelvic examination under anesthesia) with several female genital system surgery codes; and nursing facility/rest-home visit codes 99307-99310, 99324-99328 and 99334-99337 with observation codes.
 
Old way: If you had a reason to bill these code pairs, you could use a modifier to tell why the services were separately identifiable and necessary.
 
New way: Now, Medicare says that you can never justify billing them together.