Tag Archives: Cci
Keep your CCI edits in mind for PFT bundles.
When a patient presents with common respiratory conditions, your pulmonologist should perform an extensive history and examination, and may order several diagnostic tests before he can settle with a definite diagnosis to report in the claim. Along with the primary diagnosis (if achieved), you should report the patient’s signs and symptoms or else risk an audit.
Consider this scenario: The pulmonologist sees a patient for fever, shortness of breath, chest pain, weight loss, and fatigue. After undergoing a detailed history and examination, the patient becomes suspect for hypersensitivity pneumonitis, otherwise known as extrinsic allergic alveolitis (495.x). The physician orders a diagnostic bronchoscopy with fluoroscopic guidance, as well as a spirometry to verify the patient’s condition. To justify each service performed by the same provider or group, you might be accumulating payer inquiries or denials. This 2-step technique should carry you through potentially puzzling spirometry-E/M coding situations.
1. Don’t Leave Out Signs and Symptoms On Your Claim
First on your to-do list is to report the patient’s signs and symptoms. In this case, you would code 780.6 (Fever and other physiologic disturbances of temperature regulation), 786.05 (Shortness of breath), 786.50 (Unspecified chest pain), 783.21 (Loss of weight), and 780.79 (Other malaise and fatigue). Because these signs and symptoms resemble other respiratory problems, the physician performs a level four E/M and orders some diagnostic tests. Report the procedures with: 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) for the bronchoscopy with fluoroscopic guidance. Your physician is likely to perform this on a separate date. 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for the pulmonary function test (PFT); and 99214 (Office…
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,…
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…
Many of the new code pair additions involve CPT codes that debuted on Jan. 1, with CCI now halting payment if you report certain procedures together.
For instance, you’ll find vaccine administration codes 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid])and 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]) bundled into new vaccine administration code 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component), and no modifier can separate these edits. This edit prevents mixing and matching the new immunization administration codes with the old, established immunization administration codes when delivering multiple vaccines at the same visit.
In addition, CCI bundles the new subsequent observation care codes 99224-99226 into inpatient neonatal and pediatric critical care codes 99468-99476.
CCI Has Good News on the Modifier Front
Not all news coming out of the new edition of CCI is bad. Effective Jan. 1, you’ll be able to use a modifier (such as 59, Distinct procedural service) to separate the edit bundling wound care management codes 97597-97602 into the newly-revised debridement codes 11042-11044. In the past, if your pediatrician performed both procedures on the same date of service, you could not collect for both no matter what, but now you will be able to if your documentation demonstrates the separate and distinct nature of the services and you append the appropriate modifier.
Swapped pairs: In addition, CCI did an about-face on several edits this round. In the past, if you reported 94660 (Continuous positive airway pressure ventilation) or 94662 (Continuous negative pressure ventilation) with an outpatient E/M code (99201-99215), CCI would reimburse you for the pressure ventilation and deny
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|
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… Continue reading
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,…