Pulmonology Coding Alert

Know when it’s okay to unbundle edit pairs.

The National Correct Coding Initiative (NCCI) edits are released each quarter, and most coding software programs incorporate the adjustments automatically. However, without an understanding of how and why each edit is necessary, your coding could miss the mark.

Pulmonology Coding Alert has broken down the different edit types, reasoning behind each edit, and how to circumvent the edits in certain situations.

Be Familiar with NCCI Edits

The NCCI edits are a national standard for ensuring proper payment and coding. Or, as the Centers for Medicare & Medicaid Services (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 providers about edits, it’s often misunderstood that the bundled code isn’t a paid service. However, the effort and payment are already established within the primary code. Therefore, 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 misimpression 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, when CCI allows for unbundling.

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 and there is no active edit for the pair.

Example: Code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) is a Column 2 code to 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device), 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 94664 to review how to use the Acapella flutter valve and 94640 to provide treatment for the patient’s chronic obstructive pulmonary disease (COPD) exacerbation.

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.