Radiology Coding Alert

Question: I notice that some code pairs in the National Correct Coding Initiative (CCI) edits are followed by a 0 and others by a 1. What distinction is being made?

Virginia Subscriber

Answer: The CCI edits are a list of code pairs that Medicare will not reimburse together for the same patient on the same day, based on one of two relationships: 1) one code is comprehensive and includes the service of the other, component code, or 2) the two codes are mutually exclusive, such as two different lab tests that measure the same factor. Reporting two of these codes together for the same service represents fraudulent "unbundling," which is the practice of breaking down a single procedure into its component parts, and billing for additional services.

When the superscript 0 appears with a code pair, it means that Medicare never allows a modifier to be used, so the pair could be reported together. The superscript 1 means that a modifier is allowed under certain circumstances. For example, wrist x-ray codes 73100 and 73110 are considered bundled and carry an indicator of 1. As in the example in the earlier reader question, if one service is provided before fracture reduction and the other post-reduction, both may be reimbursable when reported with modifier -59 (Distinct procedural service).

Reader Questions were answered and reviewed by Donna Richmond, RCC, CPC, radiology coding specialist with Acadiana Computer Systems Inc., a medical billing management company based in Lafayette, La., that serves more than 200 radiologists, pathologists and anesthesiologists; and Gary Dorfman, MD, FACR, FSCVIR, past president of the Society for Cardiovascular and Interventional Radiology (SCVIR) and president of Health Care Value Systems in North Kingstown, R.I.