Primary Care Coding Alert

Question: If I cannot find two codes paired together in the CCI edits, how do I know which code would be considered a column 1 code and which would be considered a column 2 code so that I could put my modifier on the correct code?

New Orleans Subscriber

Answer: If you are looking through Correct Coding Initiative (CCI) edits to see if two CPT® codes are listed together (one as a column 1 code and the other as the column 2 code) and you do not find the code pair in the list of CCI edits, that indicates that these two codes are not bundled, at least for Medicare purposes or the purposes of other payers that adhere to CCI.

When you do not find any two codes paired in the list of CCI edits, then you do not have to use a modifier on either of the two codes for Medicare or other payers that adhere to CCI. You will have to use an appropriate modifier to one of the two codes to get the column 2 code paid when these two codes are listed in the CCI edits with the modifier indicator ‘1,’ which means that you can unbundle the codes using an appropriate modifier.

If two codes are listed under CCI with the modifier indicator ‘0,’ you cannot use a modifier to unbundle the two codes, and if reported together, only the code in column 1 of the CCI edit will be paid out, and the claim for the code in column 2 will be denied.

So, in most circumstances, if you do not find two code pairs in the CCI list, you won’t use a modifier with either of the two codes when you are reporting both these codes together.

However, some payers might require the use of modifiers in some cases, even when no CCI edits are in place. Check for a black box edit when reporting the two codes for a private payer. In such circumstances, depending on payer preference, you might have to use a modifier on one of the codes. Check with the payer as to which code will have to be appended with the modifier (although it will usually be the lesser valued procedural code).