Reader Question: CCI Edits

Question: I heard that HCFA has suspended version 6.3 Correct Coding Initiative (CCI) edits. Is this true?

Ohio Subscriber

Answer: HCFAs recent temporary suspension of a large portion of version 6.3 CCI edits is retroactive to Oct. 30, 2000. The agency wont reinstate any of these until July 2001. Most significant about the 6.3 edits was the bundling of E/M services with diagnostic procedures, says Barbara Cobuzzi, CPC, CHBME, president of Cash Flow Solutions Inc. in Lakewood, N.J. She further states that E/M service providers should attach modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and resubmit for reimbursement claims denied under the 6.3 edits if the service meets the separate and significant criteria.

In the APC arena, you might have to take another look at claims youve submitted using critical care codes 99291 and 99292. For example, critical care was bundled into 36000 (introduction of needle or intracatheter, vein). If you were denied payment for this service under the 6.3 CCI edits, you should resubmit the claim with modifier -25 and the documentation to support that the angiogram was separate and significant.

The explanation of medical benefits on the denied insurance form will help determine which claims to resubmit. This area of the form should indicate that the claim was denied or reduced because: 1. The service was not significant or separately identifiable or 2. Payment was included in another service received on the same day.

HCFA has pledged to work with the AMA and others to continue educating providers on how to append modifier -25 to E/M services when billed with procedures performed on the same day.

- Published on 2001-03-01