Urology Coding Alert

Tip: Keep edits in mind for other payers besides Part B MACs.

With new Correct Coding Initiative (CCI) edits going into effect every quarter, you may have trouble keeping up with the changes. CCI 19.1 gives a bit of relief, thanks to Correct Coding Initiative with few changes taking place as of April 1.

So now is a good time to step back and make sure you have a grasp on the basics. Whether you’re new to coding or you’ve been dealing with the edits for years, it is always good to refresh your CCI know-how. Test your skills with top-three frequently-asked questions that subscribers send to the Urology Coding Alert.

Modify Judiciously

Question 1: Our new office manager never allows us to use a modifier to override the CCI edits because she says that ignoring CCI edits amounts to “unbundling,” which is not appropriate. But we’ve been using modifiers to override CCI edits for years. Who is right?

Answer: 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” in column F of the CCI spreadsheet.

A “0” indicator means that you cannot unbundle the two codes under any circumstances, says Chandra L. Hines, practice supervisor of Wake Specialty Physicians in Raleigh, NC. 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.

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

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, or modifier 59 (Distinct procedural service) when two non-E/M services are performed, but other modifiers may apply in some circumstances.

For instance: CCI version 15.0 bundles 52204 (Cystourethroscopy, with biopsy[s]) into the resection codes 52234 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; small bladder tumor[s] [0.5 up to 2.0 cm]), 52235 (… medium bladder tumor[s] …), and 52240 (… large bladder tumor[s] …), but you can bypass these bundles with modifier 59 since they have a modifier indicator of “1.” If your urologist treats a bladder tumor that is larger than 0.5 cm and you report 52234, 52235, or 52240, you may also be able to separately report a bladder biopsy under certain circumstances. If the urologist biopsies normal mucosa (mapping), a bladder red patch, or only biopsies another bladder tumor, and all lesions are in distinct areas that are separate and different from the initial tumor site, report the biopsy separately. Use 52204 and append modifier 59 to indicate that the biopsy was a separate procedure at a separate site.

CCI Edits Aren’t Exclusively for Medicare

Question 2: When we’re billing a payer other than Medicare Part B, do we have to follow CCI edits, or are they Medicare-specific?

Answer: Although all Medicare Part B payers follow the CCI edits, many other payers take them into account when determining which procedures should be paid separately, Hines says.

Example: As part of the Affordable Care Act, state Medicaid programs were told to begin using CCI edits when processing claims as of Oct. 1, 2010. This means that you’ve probably seen CCI edits at work with some of your Medicaid claims. In addition, many private payers and workers’ compensation insurers also use the CCI to justify claims payment and denials. You should check with your payers to determine which use the CCI edits and which do not.

Don’t Bill Patients When Exceeding MUE Limits

Question 3: We’ve had several claims denied due to the medically unlikely edits (MUEs) that CCI has been instituting. We’ve been billing the balance to the patient but our auditor is trying to discourage us from continuing to do that. Why would that be?

Answer: CCI doesn’t actually institute MUEs; CMS does. CCI edits relate to code pairings (whether two codes can be billed together), says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. MUEs refer to a single code and limit the number of times on a date of service that a particular code can be billed, she adds.

That being said, you aren’t alone in your belief that patients can be balance billed for this, but you join many other practices in believing this common MUE myth. The reality is that even if you have the patient sign an advance beneficiary notice (ABN), you cannot pass on the cost of procedures you know will be denied due to MUEs, Cobuzzi warns. “If the practice does not agree with the MUE, and can support their coding and billing, I would recommend appealing.” Stay tuned for an article on MUEs in a future issue of Urology Coding Alert.

CMS makes this rule very clear in its FAQs (http://questions.cms.hhs.gov), stating: “A provider/supplier may not issue an ABN for units of service in excess of an MUE. Furthermore, if services are denied based on an MUE, an ABN cannot be used to shift liability and bill the beneficiary for the denied services. It is a provider/ supplier liability.”

You also shouldn’t balance bill a patient when you bill two codes together and one is denied because the codes are bundled by CCI edits.