Radiology Coding Alert

Use CCI edits and modifier status to help streamline payments and prevent denials.

There are certain instances — almost exclusively in the radiology specialty — where a particular set of guidelines may direct you to combine two procedure codes into a third, more comprehensive code. While, on the surface this might sound like unbundling, the two practices are very much distinct from one another.

“Understanding when and when not to combine imaging codes into one comprehensive code can prove especially difficult for coders,” says Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. “That’s because you’ve got to consider both guidelines and Correct Coding Initiative (CCI) edits in the decision-making process,” Della Vella explains.

Rely on this comprehensive guide for any and all diagnostic radiology scenarios in which your best bet is to combine one or more code sets.

Discern Between 2 Different Sets of Terms

The practice of bundling and unbundling code pairs is a common one in diagnostic radiology. The process is relatively simple, despite the fact that Correct Coding Initiative (CCI) edits have been known to induce headaches at times. When the provider performs two or more imaging services together, it’s your responsibility to confirm that there are no bundling edits between the respective codes. Use the analogy of a wedding. Before the vows are said, the officiant typically states something along the lines of “should anyone present know of any reason that this couple should not be joined in holy matrimony, speak now or forever hold your peace.”

The same concept essentially applies to a CCI edits check. If you perform an edit check on a code pair, it’s up to the CCI algorithm to determine whether the two codes should, in fact, be joined.

However, sometimes the guidelines call for you to combine two codes into one, more comprehensive code. In these instances, you aren’t deciding whether one code should be submitted alongside another. Rather, you are determining which all-encompassing code accurately reflects the properties of each respective procedure. However, you must first understand how these scenarios differ from scenarios in which one code bundles into another.

In the case of bundling, you will perform a CCI edits check and, depending on the results, either exclusively report the column 1 code or report both codes with an overriding modifier on the column 2 code. On the other hand, combining two codes calls for the two respective codes to be merged into a third, more comprehensive code.

Let CCI Edits, Modifier Status Guide the Way

When making the decision to bundle, unbundle, or combine, you’ll want to focus on one key component of the CCI edit — modifier status. For CCI edits with a modifier indicator of ”1,” you know that your options are either to bundle the column 2 code into the column 1 code or to use an overriding modifier (such as modifier 59, [Distinct procedural service], for example) when the situation calls for it.

Remember: CMS explains in the NCCI Policy Manual that “each (CCI) edit has a column one and column two HCPCS/CPT^® code. If a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment.”

However, there are some common misconceptions within the coding community as it pertains to CCI edits with a modifier status of “0.”

Refresher: CMS defines CCI edit modifier status codes as the following:

• 0 (Not Allowed): “There are no modifiers associated with NCCI that are allowed to be used with this » PTP code pair; there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider.”
• 1 (Allowed): “The modifiers associated with NCCI are allowed with this PTP code pair when appropriate.”
• 9 (Not Applicable): “This indicator means that an NCCI edit does not apply to this PTP code pair. The edit for this PTP code pair was deleted retroactively.”

As you can see, CCI edits with a modifier status of “0” mean that the two respective codes cannot be reported together under any circumstances.

“The answer, with respect to modifier status ‘0’ is always going to be ‘No,’” says Kimberly M. Fifer, CPC, CEDC, manager of coding operations at Revenue Cycle Management in Roanoke, Virginia. “No matter how you phrase the question or how many times you ask, you cannot bill two procedures with modifier ‘0’ status together,” Fifer instructs.

Consider the example of 77078 (Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, pelvis, spine)) and 77080 (Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)). Since these two codes have a modifier status of “0,” CCI edits instruct coders to only report the column 1 code (77078).

Put Your Knowledge to the Test

However, that doesn’t mean you should immediately disregard the column 2 code. In fact, there are certain scenarios that call for you to disregard both the column 1 and column 2 codes, instead opting for a third, more comprehensive code. This decision is ultimately left in the hands of the code pairs’ modifier status — assuming no there’s no authoritative source policy available, such as CMS, to overrule you.

Consider the example of a patient presenting for a 74150 (Computed tomography, abdomen; without contrast material) in the morning and returning for a 74160 (Computed tomography, abdomen; with contrast material(s)) in the afternoon. Since these codes have a modifier “0” status between the two, you cannot code them separately. However, instead of only reporting the column 2 code (74160), you will merge these two codes into 74170 (Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections).

While all this information at once might feel like a handful, have no fear. Keep a look out for the next issue of Radiology Coding Alert where we will apply this information to a broad list of scenarios in which you’ll rely on NCCI edits, modifier status, and organization-specific guidelines to decide if combining two codes is the correct option.