Pulmonology Coding Alert

Question: I read your article last month about the new CCI edits and I have a question. You mentioned “column 1” and “column 2” codes but we aren’t sure about the difference. We also aren’t sure how to know when we can separate an edit with a modifier and when we can’t. Can you help?

New Mexico Subscriber

Answer: When two codes are bundled together, typically the column 1 code is the one that will be paid, and the code in column 2 is the one that will be “bundled in” and therefore not reimbursed.

However, as you mentioned, there are circumstances when you can bill both codes with a modifier appended to the column 2 code. To learn whether overriding the edit is allowed, you will look in the modifier indicator column of CCI edit file, which contains 0, 1, or 9. Learn what the modifier indicators mean to ensure you use them correctly:

• 0: You cannot use a modifier to override the edit under any circumstances.
• 1: You can use a modifier to override the edit when appropriate. Remember: The documentation and clinical circumstances must always support your decision to use the modifier. Examples include separate sites or sessions for the services. Never append a modifier just to bypass the edit.
• 9: The modifier indicator is irrelevant. The typical example involves CMS deleting an edit retroactively, meaning it’s as if the edit never existed.

You can find these indicators in the CCI edit file, or you can contact your insurer if they maintain their own edits. Overriding edits should not be done automatically, if services were performed at different sessions, on different areas of the body, or for unrelated reason, it may be acceptable to append an appropriate modifier to unbundle the services. Be sure to check payer policies for any additional guidance or prohibitions that they provide for frequently unbundled services.