Urology Coding Alert

If you don't know how to override edits, you could be leaving money on the table

National Correct Coding Initiative (NCCI) edits are part of your job every day, but do you really understand how they work and the risks involved? Check out this Q&A to make sure you're up to speed.

1. What Are NCCI Edits ?

NCCI edits are pairs of CPT Codes or HCPCS Level II codes that Medicare (and many private payers) will not reimburse if you code them together, except under certain circumstances. Medicare applies the edits to services billed by the same provider for the same beneficiary on the same date of service, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, NJ.

2. What Does 'Mutually Exclusive' Mean?

NCCI contains two types of edits: mutually exclusive and "column 1/column 2" (previously known as "comprehensive/component" edits).

Mutually exclusive edits pair procedures or services that the physician could not reasonably perform at the same session on the same beneficiary, says Kelly Dennis, CPC, EFPM, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla.
 If you were to report two mutually exclusive codes for the same patient during the same session, Medicare would reimburse only for the lesser-valued of the two procedures.

3. How Do Column 1/Column 2 Edits Differ?

Column 1/column 2 edits describe "bundled" procedures. That is, CMS considers the code listed in column 2 as the "lesser" service, which is included as a component of the more extensive column 1 procedure.

If you were to report bundled (column 1/column 2) procedures for the same patient during the same session, Medicare would reimburse only for the higher-valued of the two procedures.

For example, NCCI bundles 50220 (Nephrectomy, including partial ureterectomy, any open approach including rib resection) into 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy). So, only the latter code gets paid. 

4. Can I Override NCCI Edits?

Yes, in certain circumstances you can override NCCI edits and achieve separate reimbursement for bundled codes. Follow these steps if you have distinct services:

Check the correct coding modifier indicator. Each NCCI code pair edit includes a correct coding modifier indicator of 0 or 1.

A 0 indicator means that you may not unbundle the edit combination under any circumstances, according to NCCI guidelines. An indicator of 1 means that you may use a modifier to override the edit if the procedures are distinct from one another, such as on a separate encounter on the same date, on a separate anatomical site, or for a separate indication.

Verify that the procedures are independent and distinct. You should attempt to override NCCI code pair edits only if the paired procedures are separate and unrelated, Cobuzzi says.

For instance, the provider may have provided the services/procedures at different sessions, at different anatomic locations, or for different diagnoses.

Append modifier 59. You must append modifier 59 (Distinct procedural service) (or another appropriate modifier) to the column 2 code to indicate to the payer that the billed procedures are distinct and separately identifiable, says Beth Glenn, CPC, CMA, certified coder for Jefferson Physicians in Jefferson City, Tenn."Without modifier 59, the payer will simply apply the NCCI edits and deny payment," she says.

Caution: For Medicare claims, be sure to use modifier 59 only when indicated and appropriate based on NCCI edits and guidelines. CMS statistically tracks the use of modifier 59, and providers who use it too frequently may bring about an audit.

5. How Often Are the NCCI Edits Updated?

CMS updates the NCCI every quarter, and you should always consult the most recent version when coding. Remember: Hospital edits run one quarter behind physician edits.

The number of changes each quarter varies, but almost every update contains significant changes. "You'll always want to be sure to be using the latest edition of NCCI," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. "If you're one or two versions behind, you could be coding incorrectly and not even know it."

6. How Can I Find the NCCI Edits?

You can access NCCI updates through the CMS Web site at www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp. This site contains a listing of the NCCI edits by specific CPT sections, and is available free to the public for downloading.