Modifiers are the key to overriding Correct Coding Initiative (CCI) edits, so let’s give them the attention they deserve. We’ll start with a recent rule update and move on to…
If you’re just plodding though nerve surgery claims, you could be stepping over a great deal of well-earned reimbursement. Coding and billing peripheral nerve surgeries for conditions such as tarsal tunnel and diabetic neuropathy can involve a frazzling number of codes. Podiatry coders often struggle to navigate the various coding guidelines that payers use for these procedures. Use these five tips to maximize payment for your podiatrist’s hard work on nerve surgeries:
Tip 1: Check CCI edits and your local Medicare guidelines
If you’re billing codes that the Correct Coding Initiative bundles together — and your documentation and diagnosis codes can’t justify breaking the bundle — you’re not going to see one extra cent for that bundled procedure code.
Example: A California Medicare patient injures his foot when he falls off a ladder and requires peripheral nerve surgery to correct the damage the injury caused. The podiatrist performs the following:
28035 — Release, tarsal tunnel (posterior tibial nerve decompression)
64712 — Neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve
64704 — Neuroplasty; nerve of hand or foot
+64727 — Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)
64708 — Neuroplasty, major peripheral nerve, arm or leg, open; other than specified.
If you report all these codes, you’re bound to get a denial on 64704 — this is one of the codes the Correct Coding Initiative (CCI) bundles into 28035. Unless you can justify billing 64704 separately (and if that’s the case, append modifier 59, Distinct procedural service, to the code), you shouldn’t list it all.
Unbundling is not automatic: Be aware that you can’t automatically override a CCI edit with modifier 59 just because documentation supports a separate site,...
Correct Coding Initiative version 17.1 brings 11,831 new edit pairs, effective April 1 for physicians. That’s the word from a March 17 announcement by Frank Cohen, principal and senior analyst for the Frank Cohen Group. Here’s a look at the major pointers you need to keep in mind to comply with the new cardiology-related edits, including cardiac catheterization, radiological supervision and interpretation, cardiac rehabilitation, and more.
1. Prevent Denials by Remembering 93454-93461 Are Diagnostic
New edits will prevent you from reporting heart catheter/angiography codes 93454- 93461 (column 2) with the following cardiovascular therapeutic services and procedures (column 1):
The 929xx codes in column 1 describe coronary therapies. The 934xx codes in column 2 are diagnostic procedures. You should never use the 934xx diagnostic codes in column 2 to report catheter placement and coronary angiography performed as an integral part of the therapeutic column 1 services.
Opportunity: The edits have a modifier indicator of 1, so you may override them with an appropriate modifier when the procedures are distinct. If you report both codes in the edit pair and don’t append a modifier to the column 2 code, Medicare (and payers applying Medicare rules) will reimburse you for only the column 1 code.
The AMA, via CPT Assistant (April 2005), indicates that you may report a true diagnostic catheterization in addition to the therapeutic procedures described by 92980 and 92982: “These two distinct procedures (diagnostic catheterization and therapeutic procedures), therefore, should...
If your dermatologist is treating vitiligo or dychromia patients with phototherapy, read your physician’s documentation carefully to determine what type of light, wavelength, and materials he used. These two frequently asked questions will help you combat both E/M and multi equipment correct coding initiative (CCI) situations.
Evaluate These Phototherapy + E/M Tips
If you’re charging for an office visit on the same day as phototherapy, your reimbursement may depend on whether your physician’s documentation warrants a different diagnosis code. Payers may reimburse at times if the doctor sees the patient for a different problem, thus with a different diagnosis code, experts say.
Example: If your physician performs 99212 (Office or other outpatient visit for the evaluation and management of an established patient … Physicians typically spend 10 minutes face-to-face with the patient and/or family) with phototherapy, you will bill it with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the E/M service. You can only consider reporting modifier 25 when coding an E/M service, Janet Palazzo, CPC, a coder in Cherry Hill, N.J., says. Remember your E/M documentation has to show medical necessity for the additional work.
If you reported the nurse visit code 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician …), your payer would likely consider it bundled into the light treatment.
Ask 2 Questions to Choose Best Light Therapy Code
For patients with vitiligo (709.01), your dermatologist may use narrow band UVB phototherapy.
The dermatologist administers phototherapy two to three times per week for several months until the patient achieves repigmentation of the skin. For this procedure, you need to pinpoint what types the...
Hang on to your claims for these wound care management codes.
As most veteran coders know, you can’t report an add-on code unless you report it along with its “parent code” on the same claim. But an NCCI glitch has made it impossible for you to collect for both the debridement add-on code 97598 and its partner code 97597 — creating denied claims and confusion for practices that perform active wound care management. However, a new announcement indicating that the NCCI is fixing the problem should ease your coding angst.
The American Podiatric Medical Association (APMA) issued a release on its Web site stating that the National Correct Coding Initiative (NCCI) edits currently bundle the following two codes together:
97597 — Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less
+97598 — …each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
This edit bundle has an indicator of “0,” meaning that no modifier can separate these codes. Fortunately, the APMA caught the error and contacted the NCCI director about it.
“The NCCI is currently working on a solution and recommends that APMA members delay submission of claims reporting combination of CPT 97597 and CPT 97598 until the NCCI replacement file is in place and implemented by CMS,” the APMA’s statement says. “The April 1, 2011 version of NCCI does not contain this edit error.”
The APMA has not yet gotten word on whether Medicare contractors will automatically reprocess claims that were paid in error...
Capture additional pay by separating wound care management codes 97597-97602 from the newly revised debridement codes.
Every year, just when you’re trying to get used to new CPT codes, the Correct Coding Initiative (CCI) comes along and limits how and when you can use the new codes you’ve been given. This year is no exception with CCI 17.0 adding edits involving new Renessa and posterior tibial neurostimulator (PTNS) codes, among others.
The CCI released version 17.0, revealing 19,822 new active pairs and 9,778 code pair deletions, said Frank D. Cohen, MPA, MBB, senior analyst with The Frank Cohen Group, LLC, in a Dec. 14 announcement.
Many of the new code pair additions involve CPT codes that debuted on Jan. 1, 2011 with CCI getting ready to halt payment if you report certain procedures together. Get a grip on the new bundles with this urology-focused rundown.
CPT 2011 deleted Category III code 0193T (Transurethral, radiofrequency microremodeling of the female bladder neck and proximal urethra for stress urinary incontinence), replacing it with a new Category I code 53860 with the same descriptor. CCI targets 53860 with several edits.
When your urologist performs the Renessa procedure, you’ll report 53860, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.
As of Jan. 1, when 53860 became an active code, CCI 17.0 created edit pairs with the following column 2 codes that Medicare considers usual and necessary parts of any surgery:
“In general CPT code 53680 would include catheter placement for temporary postoperative urinary drainage at the conclusion of the procedure, and therefore, these latter...
Effective Jan. 1, 2011, new CPT codes and, inevitably, new Correct Coding Initiative (CCI) physician edits are there for physicians. For version 17.0, “19,822 new edit pairs have been added to the database while 9,778 have been terminated, for a net gain of 10,044 new edit pairs,” according to Frank Cohen, MPA, MBB, of the Frank Cohen Group, in his Dec. 14, 2010, “NCCI Version 17.0 Change Analysis” announcement.
The main edits you want to be sure to watch for are those related to new code 96446 (Chemotherapy administration to the peritoneal cavity via indwelling port or catheter).
The 96446 non-mutually exclusive (NME) edits are largely what you would expect based on other chemotherapy code edits — bundles with E/M, anesthesia, venipuncture and other vascular procedures, for example. You want to be sure to watch which is the column 1 code and which is the column 2 code for these bundles.
CCI places E/M codes 99217-99239 in the column 1 position and 96446 in the column 2 position. On the other hand, CCI places 96446 in the column 1 position and E/M codes 99201-99215 in the column 2 position, as shown below:
| Column 1 | Column 2 |
| 99217-99239 | 96446 |
| 96446 | 99201-99215 |
Remember that if you report both codes in an NME edit pair without a modifier, Medicare (and payers who adopt these edits) will deny the column 2 code and pay you only for the column 1 code. The edits in the table above all have a modifier indicator of 1, meaning that you may override the edits with a modifier when appropriate, such as in the case of distinct,...
Raise your glass to the new year without worries of 2011 medical code changes. SuperCoder’s got you covered with new CPT codes, CCI edits, and supply coding revisions. Starting Dec. 31, SuperCoder.com will offer the complete codesets for CPT 2011...
Question: If a nurse has to check vitals to make sure an allergy injection is the correct quantity or if she has to educate the patient about the administration or side effects of the injections, we’ve been billing 99211 with 95115 or 95117. There is...
When your urologist fragments more than one stone located in two different locations within the urinary tract during one operative session, the proper coding might leave you scratching your head: Can you ever report both procedures? If you can, how do you sequence the codes? Tackle these tough questions by reviewing a sample scenario.
Your urologist performs a ureteroscopic laser lithotripsy of a left ureteral stone and lithotripsy of a bladder stone. How should you code these procedure performed during one operative session?
Separately Report Procedures Based on Anatomy
Depending on where the stones are in the urinary tract, you may be able to separately report and be paid for multiple fragmentation procedures during the same session. For a ureteroscopic fragmentation of a ureteral or renal pelvic stone your urologist performs, you’ll report 52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]). Remember that 52353 applies to “any type of fragmentation, whether you use a Holmium laser, a Candela laser, a mechanical lithotripsy, or an ultrasonic lithotripter,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. If your urologist also fragments a bladder calculus during the same session, your coding will then depend on the different and separate anatomical location of the stones. Therefore, in the sample scenario, you can separately report those procedures. “We are dealing with two separate portions or parts of the urinary tract – a ureteral stone and a bladder stone,” Ferragamo explains.
According to the Correct Coding Initiative (CCI), codes 52317 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small [less than 2.5 cm]) and 52318 (…complicated or large [over 2.5 cm]) are bundled with 52353. Because both bundles have a...
Question: Sometimes I cannot find my two-code pair in the CCI edits. How do I know which code would be considered a column 1 code and which would be considered a column 2 code, so that I could put my modifier on the correct code?
Answer: If the codes are not listed, the codes are not bundled per the Correct Coding Initiative (CCI). You would not need a CCI modifier, such as 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), 57 (Decision for surgery), or 59 (Distinct procedural service), to override the edit when appropriate.
A private payer could have a black box edit. You would need to check with a rep for a recommendation.
Watch out: Just because a code does not have a bundle in CCI does not mean a modifier is out of the picture. While you won’t need a CCI modifier to override the edit, you might need apayment modifier.
You can find Medicare’s other allowed modifiers for any given CPT code in the Medicare Physician Fee Schedule (MPFS). Columns Y-AC indicate if modifier 51 (Multiple procedure), 50 (Bilateral procedure), etc. apply.
To determine which code receives modifier 51, you need to know the code’s relative value units, which are also listed in the MPFS. Private payers may not adjust claim items in descending order as Medicare’s Outpatient Code Editor software does. If you append modifier 51 to a higher valued item, the private payer may apply the adjustment based on your coding, costing you payment. You should instead list the items in descending relative value order from highest to lowest. Append modifier 51 to the lower priced procedure as necessary. The insurer will then apply the typical 50 percent,...
Version 16.3 of the National Correct Coding Initiative (CCI) edits initiated many new edit pairs on Oct. 1. You’ll need to get to know new edits affecting your small and large bowl injury repairs, open ureterotomy stentings, and diagnostic laparoscopy coding.
Count Bowl, Splenic Injury Repairs With Main Surgery
If your urologist has to perform a small or large bowl repair for an intestinal injury that occurs during an open urological or urogynecological procedure, you’ll likely be facing a new CCI edit dilemma.
CCI bundles column 2 codes 44602 (Suture of small intestine [enterorrhaphy] for perforated ulcer, diverticulum, wound, injury or rupture; single perforation), 44603 (… multiple perforations), 44604 (Suture of large intestine [colorrhaphy] for perforated ulcer, diverticulum, wound, injury or rupture [single or multiple perforations]; without colostomy), and 44605 (… with colostomy) into many of the procedures in the 50010-57280 range.
Silver lining: These edits have a modifier indicator of “1,” which means you can bypass the edits in some clinical circumstances, using a modifier such as 59 (Distinct procedural service). “These bundles indicate that a repair of an inadvertent small or large bowl injury occurring during urological or urogynecological surgery will be included in the primary procedure under most circumstances and should not be billed separately,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. “If such an injury does occur and is repaired, the surgeon should check CCI, version 16.3 edits to determine if their primary procedure is involved in these edits.”
If, during a urological procedure such as a difficult left nephrectomy, an inadvertent splenic injury occurs, resulting in an open splenectomy (38100, Splenectomy; total [separate procedure]), a partial splenectomy (38101, … partial [separate procedure]), or a laparoscopic splenectomy (38120, Laparoscopy, surgical, splenectomy)...
The National Correct Coding Initiative (CCI) version 16.3 instructions align MTWA and stress tests coding manual guidelines with version 16.2 edit deletions.
Update Chapter 11 of Your CCI Manual
The CCI version effective July 1 deleted the edits that barred reporting cardiovascular stress test codes 93015-93017 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress …) with MTWA code 93025 (Microvolt T-wave alternans for assessment of ventricular arrhythmias).
The manual in effect at that time, however, stated you couldn’t report 93015-93017 on the same date as 93025. The previous wording said, “If a physician performs an MTWA with submaximal stress test followed by a traditional stress test on the same date of service, CMS payment policy allows separate payment of MTWA (CPT code 93025) and the interpretation and report for the traditional stress test (CPT code 93018). The practice expense component of the traditional stress test is not separately payable, and a physician should not report CPT codes 93015-93017 on the same date of service as CPT code 93025.”
CCI’s updates present in the current manual, version 16.3, reflect the CCI edit deletion that allows you to report both an MTWA with submaximal stress test and a traditional stress test, acknowledging that the tests are different. The current wording says, “Microvolt T-wave alternans (MTWA) (CPT code 93025) testing requires a submaximal stress test that differs from the traditional exercise stress test (CPT codes 93015-93018) which utilizes a standard exercise protocol. CPT codes 93015-93018 should not be reported separately for the submaximal stress test integral to MTWA testing. If a physician performs an MTWA with submaximal stress test followed by a period of rest and then a traditional stress test on the same date of service, both the MTWA and traditional...
Only report primary procedure – except for 99455 edits.
The latest version of the National Correct Coding Initiative (CCI) edits went into effect October 1, and introduced a slew of pairings involving two new Category III “T” codes for transforaminal epidural injections:
Explanation: “The new Category III codes 0228T-0231T have added the addition of ultrasound guidance to transforaminal epidural injections,” says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, CEO of Healthcare Consulting and Coding Education in Boardman, Ohio. “That will eliminate the need to code the ultrasound independently.” The existing, Category I codes for transforaminal epidural injections of anesthetic and/or steroids (64479-64484) include only the injection itself.
Even Simple Procedures Rule With NME Edits
CCI classifies the bulk of edits involving 0228T and 0230T as non-mutually exclusive.
No breakage: The rationale behind the new bundling edits falls to “standards of medical/surgical practice.” Most edits carry a modifier indicator of “0,” which means you cannot break the edit with a modifier and report both codes during a single encounter.
Examples of common procedures that override the accompanying 0228T or 0230T codes include:
...
You can sit back and enjoy the fall foliage spectacle — SuperCoder.com’s got your ICD-9-CM 2011, National Correct Coding Initiative 16.3, and October Medicare Physician Fee Schedule medical coding updates covered. Go ahead and search for th...
AMA corrects vestibular test codes to allow partial reporting.
The Correct Coding Initiative (CCI) came down hard on practitioners who perform vestibular testing earlier this year, but a new correction, effective Oct. 1, should ease the restrictions and help the otolaryngology, neurology, and audiology practices that report these services.
The problem: CCI edits currently restrict practices from reporting 92541, 92542, 92544, and 92545 individually if three or less of the tests are performed, notes Debbie Abel, Au.D., director of reimbursement and practice compliance with the American Academy of Audiology.
The solution: Starting October 1, 2010, “if two or three of these codes are reported for the same date of service by the same provider for the same beneficiary, an NCCI-associated modifier may be utilized to bypass the NCCI edits,” CMS wrote in a decision to alter the edits.
The American Speech-Language-Hearing Association (ASHA) has requested “clarification regarding the correct NCCI-modifier to use when reporting the codes to Medicare,” noted Lemmietta G. McNeilly, PhD, CCC-SLP, CAE, chief staff officer of Speech-Language Pathology with ASHA, in a July 29 announcement.
Look for Changes to Vestibular Testing Descriptors
The root of the CCI problem began when the 2010 CPT manual was published, including new code 92540 (Basic vestibular evaluation …) and the subsequent codes following it, which make up the individual components of 92540. “The clarification that resulted in the NCCI edits being lifted should be included in upcoming versions of the manual,” Abel tells Part B Insider.
According to the AMA’s Errata page, code descriptors should read as follows, effective Oct. 1:
...