Urology Coding Alert

Hint: Look beyond Medicare.

Whether you’re new to coding or a seasoned urology coder, knowing the ins and outs of the Correct Coding Initiative (CCI) edits can determine the success of many of your claims. Check out these three common CCI questions — and the experts’ answers — to increase your CCI knowledge and avoid denials.

What Exactly is a CCI Edit?

Every quarter CCI puts out a list of pairs of CPT® and HCPCS codes that payers will not reimburse when you bill them together for the same patient on the same date of service. CCI edits include two types of edits: mutually exclusive and “column 1/column 2” edits.

Here’s the difference: Mutually exclusive edits pair procedures or services that the physician could not reasonably perform together. “Mutually exclusive edits are code pairs that [CCI] has determined are unlikely to be performed on the same patient on the same day,” says Christy Shanley, CPC, CUC, billing manager for the department of urology at the University of California, Irvine.

For example, CCI lists 81000 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy) as mutually exclusive of 81001 (… automated, with microscopy). You would not perform both an automated and non-automated urinalysis from the same patient specimen collection.

Column 1/column 2 edits describe “bundled” procedures. The column 1 code generally represents the comprehensive service, and the column 2 code is the component that is part of the more extensive column 1 procedure. “Column 1 codes are codes that are primarily payable,” says Elizabeth Hollingshead, CPC, CUC, CMC, CMSCS, coding specialist at Central Ohio Urology Group in Marysville, Ohio. “Column 2 codes are the codes that are bundled into the column 1 codes. If they are billed together, the code in column 2 will be denied unless it is has a modifier indicator of 1 and it is appropriate to add a proper modifier to break the bundle.”

Payment woes: If you bill two mutually exclusive codes for the same patient on the same day, payers following CCI rules will pay only for the lesser valued of the two procedures. Conversely, if you bill bundled (column 1/column 2) procedures for the same patient on the same day, payers will pay you only for the higher-valued of the two.

What Is a Modifier Indicator?

Every CCI edit pair has a modifier indicator, displayed in column F of the CCI spreadsheet.

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

In other words: “An indicator of 0 lets you know that there is no modifier that you can apply to a code to make it payable if there is a CCI edit in place bundling it with another code,” Hollingshead explains. “An indicator of 1 means you may be able break the bundle with an appropriate modifier.”

Tip: The most common modifiers that urology practices use to override an edit pair are 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) when used with an associated E/M code and modifier 59 (Distinct procedural service) or one of the X{EPSU} modifiers when two non-E/M services are performed, but other modifiers may apply in some circumstances.

Be careful: Just because a bundle has a modifier indicator of “1,” that doesn’t mean you should automatically attach a modifier and report both codes.

“Just because you may be able to break a CCI coding bundle by using a modifier, doesn’t mean you should,” Hollingshead warns. “Never make it a blanket practice to apply modifiers when there is an edit in place just to get paid. Each encounter should be evaluated individually to see if it is clinically appropriate to break the bundle.”

Does CCI Matter For Non-Medicare Payers?

Although all Medicare Part B payers follow the CCI edits, other payers may also take them into account when determining which procedures should be paid separately.

Best bet: Check with your payers to see if they follow CCI edits, and if they have internal bundling edits that override CCI guidance. “Many commercial payers generally have edits very similar to CCI, but you’ll need to contact your payers to find out their edit methodology used,” Hollingshead advises.

Important: If you bill for a hospital, keep in mind that hospital edits run one quarter behind physician CCI edits.

Resource: You can access the quarterly CCI edits at www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp.