Stay 
Informed About NCCI Policy 
Manual Changes

Stay 
Informed About NCCI Policy 
Manual Changes

Not knowing the most current edits can cause costly coding errors.

Each quarter, the Centers for Medicare & Medicaid Services (CMS) releases an updated version of the National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits and medically unlikely edits (MUEs). The NCCI Policy Manual for Medicare Services (Policy Manual) that explains many of these edits is updated only once a year, however, in January. This can lead to inconsistencies in coding policies if changes occur to the edit tables after the release of the Policy Manual. Last year’s quarterly updates and this year’s Policy Manual set a perfect example.

Shoulder Scopes

Confusion occurred in July 2016 when CMS deleted the edits bundling 29823 Arthroscopy, shoulder, surgical; debridement, extensive with three other arthroscopic procedures of the shoulder. The updated edit tables indicated a modifier was no longer required for 29823 when reported with certain shoulder arthroscopy codes for the debridement to be separately payable. Per the 2016 Policy Manual, however, CMS considered the shoulder one anatomical joint, and all debridement codes (limited and extensive) were bundled to other shoulder scope codes.

The 2017 NCCI Policy Manual provides clarity. Effective Jan. 1, 2017, CMS will permit 29823 to be billed with:

29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)

29827 with rotator cuff repair

29828 biceps tenodesis

There is one caveat: The extensive debridement must be performed in different areas of the same shoulder to be billed with any of these three procedures.

For example, the rotator cuff is comprised of several muscles, including the supraspinatus, infraspinatus, and subscapularis. Thus, debridement of fraying of the subscapularis, supraspinatus, and infraspinatus would bundle into an arthroscopic rotator cuff repair (29827). The extensive debridement would be a component of the rotator cuff repair and not eligible for separate reimbursement.

CMS still considers the shoulder to be one anatomical joint, and extensive debridement billed with other procedures (other than 29823, 29824, or 29827) remains bundled or included, even if performed on other areas of the same shoulder. Limited debridement also remains bundled into other shoulder arthroscopy procedures, even if performed in different areas of the same shoulder.

Debridement may be separately reportable if performed on a different joint or on a site unrelated to the joint. Providers and coders are encouraged to check insurance carrier policies. Some carriers have different interpretations of modifier 59 Distinct procedural service or the new X{EPSU} subset, to the extent that some consider the wrist and ankle single anatomic joints for bundling purposes. Two or more procedures in these areas may bundle for those specific payers, even if performed in different joints or incisions at the same site.

Edits Apply for Same
Provider, Patient, Date of Service

In nearly every chapter of the Policy Manual, CMS includes a general policy statement:

MUE and PTP edits are based on services provided by the same physician to the same beneficiary on the same date of service. Physicians should not inconvenience beneficiaries nor increase risks to beneficiaries by performing services on different dates of service to avoid MUE or NCCI PTP edits.

This statement is consistent with the American Medical Association (AMA) CPT® surgery package guidelines, as well as CMS global period and relative value unit (RVU) policies, and allows physicians and other non-physician practitioners to provide properly documented and medically necessary services during the global period without fear of incorrect denial of services based on the NCCI PTP and MUE edits.

Incidental Surgical Procedures

CMS clarifies in the Policy Manual that a definitive surgical procedure requiring access through diseased tissue is a singular service. In other words, the access is not separately reportable, including debridement, incision and drainage, excision, -ectomy, -otomy, -plasty, resection, insertion, revision, replacement, relocation, removal, or closure.

This clarification is important for planned, staged, or repeat procedures. For example, some patients have complete joint replacement surgeries at an early age. The implants and hardware have a limited lifespan and revisions or replacement surgery may be required later in life. Individuals who have a shoulder injury requiring rotator cuff repair surgery may require revision if the shoulder is overused after surgery. Access to the joints through the adhesions and scar tissue are not separately reportable — meaning, no more reporting of debridement.

Unfortunately, the new language creates an opportunity for providers to overuse modifier 22 Increased procedural services. For example: A patient had an arthroscopic rotator cuff repair (29827) six years ago, and returns for revision surgery in 2017. It would not be appropriate to append modifier 22 to 29827 for the unusual amount of time spent performing the procedure due to the scar tissue (adhesions) and hardware still present in the rotator cuff from the previous surgery. The Policy Manual indicates that debridement is included in the revision surgery; the debridement of the adhesions or scar tissue would be incidental and included in the primary surgical procedure. The provider would not be allowed to report 29822 or 29823 with or without a modifier because all the debridement is performed in the same area of the shoulder.

To ensure this, CMS added a statement:

NCCI PTP edits define when two procedure HCPCS/CPT codes may not be reported together except under special circumstances. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together when the two procedures are performed at different anatomic sites or different patient encounters. … Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass an NCCI PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.

Nerve Injections

MUE edits were updated for nerve blocks. To prevent incorrect reporting of nerve blocks, CMS now limits nerve blocks (64400-64530) to a single unit of service. Multiple injections around the same nerve and/or the branches of the singular nerve during the same encounter are reported as one unit.

Fracture Care, Dislocations,
Casting, Strapping, and Splinting

The Policy Manual now states not to report casting, strapping, and/or splinting for dressing application after a therapeutic procedure. For example, a patient has a finger fracture, resulting in a laceration to the same finger. The provider performs an intermediate laceration repair down through the superficial fascia with layered closure. The provider then applies a splint to stabilize the fracture. In this case, both services may be reported.

Open fractures are different. If a physician performs debridement at the open fracture site, this service is separately reportable with the CPT® code for treatment of the open fracture or dislocation. With this example, a physician may not report the application of casting, splinting, or strapping separately.

If a patient has a finger laceration without fracture, and the provider performs a simple laceration repair with splint application as a dressing to protect the laceration, the splint application is not separately reportable, per the Policy Manual.

Previously, emergency room physicians were eligible to report an evaluation and management (E/M) service separately with a casting, strapping, or splinting service. CMS treats emergency room E/M services (99281-99285) similar to all other E/M services (99201-99499), and states in the Policy Manual that they may be reported “if and only if” the E/M service is significant and separately identifiable. This policy applies the global surgical package to casting, strapping, and splinting codes, which are minor surgical procedures with a 000-day global period. The E/M is not separately reportable for the decision to perform the minor surgical procedure.

Midnight Rule and Coding of Pulmonary Services

CMS updated the guidance concerning hospital outpatient services that cross midnight. It is common for patients to enter the emergency and continue to receive services after midnight (e.g., infusion services, an intravenous push, or pulmonary services).

For pulmonary services, the policy manual states, “An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.” This makes a difference for inhalation treatment code 94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device. If the patient has two separate hospital visits on the same date and receives inhalation treatment during each separate hospital visit, the second service is reported with modifier 76 Repeat procedure or service by same physician or other qualified health care professional. If the patient stays in the hospital continuously on the same date or even after midnight, however, the coding for the inhalation treatment could be different for inhalation treatment exceeding an hour. The first hour is reported as 94644 Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour, and the second hour is reported with +94645 Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour (List separately in addition to code for primary procedure).

This policy statement could arguably be applied to other services in a facility setting because the episode of care is defined as beginning at the time the patient arrives at the facility and ending when the patient leaves the facility. This might apply to infusion therapy services, where standard care or hospital protocol may dictate establishing an intravenous line for patients arriving in the emergency room, and any other services that cross midnight.

Diagnostic Radiology Services

There are separate codes for X-ray of the entire spine (72081-72084) and for specific regions of the spine (72020-72120). All codes are based on the number of views; however, if a provider performs an X-ray of the entire spine and an X-ray of a specific spinal region during the same encounter, the provider should report the appropriate code from range 72081-72084 based on the sum of all views taken. A provider should not report codes for the entire spine and codes for a specific spinal region for X-ray services performed during the same encounter.

The 2017 Policy Manual also provides clarification regarding 73630 Radiologic examination, foot; complete, minimum of 3 views. Per CMS, this code includes an X-ray of the calcaneous (heel) and toes, which are anatomical parts of a foot. As such, a physician should not report either 73650 Radiologic examination; calcaneus, minimum of 2 views, or 73660 Radiologic examination; toe(s), minimum of 2 views with 73630 for the same foot on the same date of service.

The 2017 Policy Manual also has changes to molecular pathology, microbiology, and laboratory services. Given the multitude of changes in this section, if you are involved with the billing, coding, and reimbursement of these services for payers adopting NCCI, carefully review Chapter X (10) of the 2017 Policy Manual to ensure proper coding.

Michael Strong

Michael Strong

Michael Strong, MSHCA, MBA, CPC, CEMC, is the bill review technical specialist at SFM Mutual Insurance Company. He is a former senior fraud investigator, with years of experience performing investigations of fraud and abuse. Strong also is a former EMT-B and college professor of health law and communications. He is a member of the St. Paul, Minn., local chapter, and can be contacted at michaelallenstrong@yahoo.com.
Michael Strong

About Has 5 Posts

Michael Strong, MSHCA, MBA, CPC, CEMC, is the bill review technical specialist at SFM Mutual Insurance Company. He is a former senior fraud investigator, with years of experience performing investigations of fraud and abuse. Strong also is a former EMT-B and college professor of health law and communications. He is a member of the St. Paul, Minn., local chapter, and can be contacted at michaelallenstrong@yahoo.com.

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