Radiology Coding Alert

Plus: 835 edit deletions mean you can't assume the usual bundles are in place.

With the implementation of Correct Coding Initiative (CCI) 17.3 on Oct. 1, 2011, expect trouble if you try to report chest X-rays with certain chest procedures. Here's a look at what's new for bundles.

2-Doctor Rule Overcomes Chest X-Ray Issues

The latest version of CCI adds 1,380 new edit pairs, according to Frank Cohen, principal and senior analyst for The Frank Cohen Group, LLC, in his NCCI 17.3 Update (available at www.frankcohen.com/html/access.html).

Some of the new edit pairs you'll want to keep an eye on bundle chest X-rays into chest tube procedures, as shown in Table 1. The reason given was "misuse of column two code with column one code."

These edits have a modifier indicator of 1, so you may override the edits with a modifier on the column 2 code when the services are distinct. For example, suppose Dr. R inserts an indwelling tunneled pleural catheter with a cuff in the morning (32550). Later the same day, the patient's condition changes and he requires a frontal chest X-ray, which Dr. R interprets (71010-26, Professional component). You may then override the edit using modifier 59 (Distinct procedural service) on 71010.

Refresher: Let's take a closer look at overriding edits. In certain clinical circumstances you can override -- not ignore -- CCI edits and receive separate payment for bundled codes. To find out if you can separately bill services, first check the "modifier indicator."

How it works: "All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2)," explains Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, consultant with MJH Consulting in Denver. "Codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1, unless the edits permit the use of a modifier associated with CCI."

A "0" indicator means that you cannot unbundle the two codes under any circumstances. An indicator of "1," however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate payment.

Tip: The most common modifiers that Part B practices use to override an edit pair are 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when used with an associated E/M code, or modifier 59 when two non-E/M services are performed and no other modifier is available to report the two separate and distinct services, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Network Oversight at Mount Sinai Medical Center Compliance Department in New York City.

"Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual," Mac says. "However, when another already established modifier is appropriate, it should be used rather than modifier 59."

Provider matters: Recall Hammer's comment above that the edits apply "if performed on the same day on the same patient by the same provider."

The rule means that if a surgeon performed one procedure of the edit pair (such as 32422) and your radiologist interpreted a chest X-ray (such as 71020-26) for the same patient, you may report 71020-26 and the edit will not apply.

You'll find this rule in the "Introduction for National Correct Coding Initiative Policy Manual for Medicare Services" (part of the NCCI Policy Manual at www.cms.gov/NationalCorrectCodInitEd/).

AV Shunt Codes Play a Large Role in Deletions

This version of CCI deletes 835 pairs, noted Cohen. A large number of those eliminate edits with vascular introduction and injection procedures in column 1. In fact, more than 10 percent of deletions involved edits with a column 1 code of 36147 (Introduction of needle and/or catheter, arteriovenous shunt created for dialysis [graft/fistula]; initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report [includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava]).

Among the large number of deletions, you'll especially want to pay attention to the deletion of edits with a modifier indicator of 0. Recall that you are not allowed to override the edits with an indicator of 0. So the deletion of those edits means that you may now consider reporting those services together on the rare occasion the physician performs them on the same date for the same patient. The now deleted edits that had a modifier indicator of 0 included those in Table 2: