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Pulmonology Coding Alert

Reader Question:

Double-Check NCCI Edits, Your Modifier Use

Published on Fri May 21, 2004

Question: The insurance company denied a claim, stating that a procedure is inclusive to the primary procedure. What step can we take to easily and clearly show that the procedure is not inclusive?

Colorado Subscriber

Answer: First, double-check the National Correct Coding Initiative (NCCI) edits to make sure Medicare doesn't bundle the procedures. Also, if you used modifiers, be sure you used them appropriately.

For example, you can't attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to a procedure code like 31622 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]).

If you correctly reported the services, your practice should formally appeal the denial. Provide the insurer with documentation that supports your claim, such as NCCI edits and pages from the CPT manual. Get the insurer's response in writing for your records.
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