Pulmonology Coding Alert

Don't override another NCCI edit until you read this

National Correct Coding Initiative (NCCI) edits are part of your job every day, but do you really understand how they work and the risks involved? Check out this Q&A to make sure you're up to speed.

1. What Are NCCI Edits?

NCCI edits are pairs of CPT or HCPCS Level II codes that Medicare (and many private payers) will not reimburse if you code them together, except under certain circumstances.
 
Medicare applies the edits to services billed by the same provider for the same beneficiary on the same date of service, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, NJ.

2. What Does 'Mutually Exclusive' Mean?

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

Mutually exclusive edits pair procedures or services that the physician could not reasonably perform at the same session on the same beneficiary, says Kelly Dennis, CPC, EFPM, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla.

If you were to report two mutually exclusive codes for the same patient during the same session, Medicare would reimburse only for the lesser-valued of the procedures.

3. How Do Column 1/Column 2 Edits Differ?

Column 1/column 2 edits describe "bundled" procedures. That is, CMS considers the code listed in column 2 as the "lesser" service, which is included as a component of the more extensive column 1 procedure.

If you were to report bundled (column 1/column 2) procedures for the same patient during the same session, Medicare would reimburse only for the higher-valued of the two procedures.

For example, NCCI bundles 31717 (Catheterization with bronchial brush biopsy) into 31622 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing). So, only the latter code gets paid.

4. Can I Override NCCI Edits?

Yes, in certain circumstances you can override NCCI edits and achieve separate reimbursement for bundled codes. Follow these steps if you have distinct services:

Check the correct coding modifier indicator. Each NCCI code pair edit includes a correct coding modifier indicator of "0" or "1." A "0" indicator means that you may not unbundle the edit combination under any circumstances, according to NCCI guidelines. An indicator of "1," however, means that you may use a modifier to override the edit if the procedures are separate and distinct from one another.

Verify that the procedures are independent and distinct. You should attempt to override NCCI code pair edits only if the paired procedures are separate and unrelated, Cobuzzi says. For instance, the provider may have provided the services/procedures at different sessions, at different anatomic locations, or for each different diagnosis.

Append modifier 59. You must append modifier 59 (Distinct procedural service) (or another appropriate modifier) to the column 2 code to indicate to the payer that the billed procedures are distinct and separately identifiable, says Beth Glenn, CPC, CMA, certified coder for Jefferson Physicians in Jefferson City, Tenn. "Without modifier 59, the payer will simply apply the NCCI edits and deny payment," she says.

5. How Often Are the NCCI Edits Updated?

CMS updates the NCCI edits every quarter, and you should always consult the most recent version when coding. Remember: Hospital edits run one quarter behind physician edits.

The number of changes each quarter varies, but almost every update contains significant changes. "You'll always want to be sure to  use the latest edition of NCCI," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "If you're one or two versions behind, you could be coding incorrectly and not even know it."

6. How Can I Find the NCCI Edits?

You can access NCCI updates through the CMS Web site at www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp. This site contains a listing of the NCCI edits by specific CPT sections, and is available free for downloading to the public.