Tammy: Q: [NCCI Edits] - I wanted to know if someone can clarify some confusion I have
about when multiple surgeries are done on a patient but the codes the physician is using
conflict with each other because of CCI Edits. How is the procedures billed if CCI Edits
say the CPTs cannot be billed together?
A: In answering this question, I just assumed that you already knew that we have two or
three columns when you’re looking at the edits depending on what format you’re looking
at the edits in so that you know where your comprehensive codes are and then the ones
that are included and then we have a column in which we’re going to have some of the
indicators on edit beside it. The short answer to your question is you would
be able to bill them with a modifier. That’s the short answer; it may not always be the
right answer. The CCI will have either a 0, 1, or 9 beside the edit in that column; if
it is a 1, then a modifier is allowed to override your edit and both procedures can be billed
together or multiple procedures depending on.
Now here’s the long answer; first we have to understand what the 0, 1, or 9 means in
the edits. Zero means there’s no way any payer is ever going to pay for that combination
or column of codes. Nothing you do or add is going to change that, flat out, never going
to get paid; so you can’t bill it together. One means that you can add a modifier to your
column 2 code if it meets that criterion for unbundling, (e.g. separate lesion, separate
site, separate incision or separate session). Nine means that it’s mutually exclusive;
that means those two codes would always be a part of the procedure, so it can’t billed.
It just goes hand in hand. Once again, there’s nothing you can do about that, no modifier
is going to help you out.
If the procedures your physicians are billing have an edit of 1 in the column, then review
the documentation. A lot of times physicians just don’t know that codes will bundle together.
I put a little example in here, I had a surgeon one time that had a little “cheat sheet”
that his staff had made. He was using it to submit charges to us on it.. He’d have 6
codes circled, and when we put them in, we get edits on four of them. Finally, I had
to ask him about it because they all got an edit of 1, so I could have added a modifier
to get them paid. When I questioned him about it, he said, “Oh, I was just circling it
so you’d know how to bill it.” He had no clue what those codes meant because nobody
gave him the full description of those codes.
JoAnne: Unbelievable.
Tammy: What’s so bad is he did this for three years.
Alicia: He’s not the only one.
Boyd: Men never ask for directions, you should know that.
Tammy: I know, he thought he was helping us out. He said he circled everything he did
because all he got was one-word descriptions on there; he didn’t realize it was all one
code. Anyway, when you are reviewing your documentation or when I review documentation,
look at the CPT’s description of separate procedures that’s found in the Surgery guidelines,
you want to know what that separate procedure is going to be. It’s going to be a different
session, it’s going to be a different procedure or surgery, or a different site or organ system,
separate incision/excision, separate lesion or separate injury.
You also have to know your carrier’s guidelines on some of these. Billing rotator cuffs for
Medicare; Medicare thinks that a shoulder joint is all one joint and they don’t pay
for the separate compartments that you may be doing something in; whereas, another insurance
carrier even though those codes would edit out, you could put that modifier on there
and get both paid, so you want to make sure your you know your carriers very well, too.
Quick examples: Removal of a 1 cm benign skin lesion on the right arm and a skin biopsy
on the left arm. Code 11100 is a column two code paired with 11401, but it has an edit
of (1). Because the biopsy was on a different site we could bill with a modifier; so it
would 11401 and then 11100-XS is what I would use. Some people use XU, some of you may still
be using (-59). I don’t know how that’s working for you, but it still exists. We’re
not allowed to use them anymore.
Left Heart Cath – I was disappointed that this became a bundling issue this year – 93458.
If we place a stent, 92928, those two codes are going to edit out. 93458 is a column two
code, it does have an edit of (1). In this case, I would bill the 93458-XU or a modifier-59
and then the 92928-RC for the stent placed in the right coronary.
Documentation is the key to this. It isn’t just enough to say they did it, but you need
to know why they did it. A lot of physicians will say, “Yeah, I did it! Just stick a
-59 on there and get it paid.” That’s a no-no, very big no-no. It has to be done
for a distinct reason on there; so just review their documentation and depending on which
edit you can do, then sure you can get them paid.
Alicia: Fantastic! Again, not only knowing the coding, but it’s very important to know
that billing aspect as well. That definitely shows how important it is.