Primary Care Coding Alert

Plus: You can also override bundles with modifiers LM and RI

Coders learned years ago that if a CCI edit indicator is listed as "1," you can separate the bundle (and report both procedure codes) using modifier 59 "or another suitable modifier." You’ll have more possibilities for what’s considered "another suitable modifier" in 2013, thanks to CMS introducing four more modifiers that Medicare contactors will accept to bypass CCI edits.

Background: When a CCI coding combination is listed as either a mutually exclusive or comprehensive/component edit, the general rule is that both codes cannot be reported separately. However, two CCI indicators are commonly used to indicate when you can, in fact, report the procedures together under circumstances. An indicator of "0" indicates that it is never acceptable to bill these procedures together, and an indicator of "1" indicates that these codes are considered bundled but can be billed separately under certain circumstances, such as a separate site, separate incision, or separate injury.

Most coders who are trying to separate CCI edits will use either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for edits involving E/M codes, or modifier 59 (Distinct procedural service) for bundles that involve two procedures. However, coding experts have long maintained that modifier 59 should be the modifier "of last resort," making many coders reluctant to use it extensively.

Latest news: CMS Transmittal 1136, released on Nov. 1, 2012, announced that you’ll be able to use the following modifiers to override a CCI edit with a modifier of "1" effective Jan. 1, 2013:

LM (Left main coronary artery)

RI (Ramus intermedius)

24 (Unrelated evaluation and management service by the same physician during a postoperative period)

57 (Decision for surgery)

Modifiers LM and RI will mainly be used by heart surgeons, but coders in other specialties are familiar with the other two additions. Both modifiers 24 and 57 can be appended to E/M codes when the E/M service is either unrelated to a surgery or during the post-op period on the same day (modifier 24) or results in the decision to perform the bundled procedure (modifier 57).

Resource: To read the complete transmittal, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1136OTN.pdf.