Cardiology Coding Alert

CCI Edits:

Conquer Column 1, Column 2, and Modifier Indicators in Your Cardiology Practice

Published on Thu Apr 29, 2021

Hint: If the modifier indicator is “0,” you can never break the PTP edit.

When you submit claims in your cardiology practice, it’s imperative to check the National Correct Coding Initiative (CCI) edits and know which codes you can report in conjunction with each other. Recently in the webinar “The National Correct Coding Initiative and Medically Unlikely Edits,” Arlene Dunphy, provider outreach and education consultant at the Medicare administrative contractor (MAC) National Government Services (NGS), reviewed how the procedure-to-procedure (PTP) CCI edits work and why they are important to coders.

Editor’s note: There are two types of PTP edits, those for physicians and those for hospitals. We will be talking only about the PTP edits that impact physicians.

Read on to get back to the basics with PTP CCI edits in your cardiology practice.

First, Understand CCI PTP Edits

PTP pair edits are just one type of CCI edits. There are also medically unlikely edits (MUEs) and add-on codes.

“PTP edits were developed to promote national correct coding methods, to control improper coding leading to inappropriate payments for Medicare claims, and to prevent unbundling of services,” according to Dunphy. PTP edits are updated quarterly.

CCI’s coding policies are based on the CPT^® manual, the HCPCS manual, national and local Medicare policies, and coding guidelines that national societies developed.

Where to find: You can find the latest CCI edits at https://www. cms.gov/Medicare/Coding/NationalCorrectCodInitEdCMS.gov. The most recent edits were effective on April 1, 2021.

See How PTP Edits Work

When your provider submits two codes, the Column 1 is eligible for payment, but Medicare will deny the Column 2 code unless both codes are clinically appropriate, according to Dunphy. Also, your provider must include the supporting documentation in the medical record.

CCI does not include all possible code combinations, so providers are obligated to code correctly, even if edits do not exist, Dunphy said. Services that are denied based on PTP code pair edits may not be billed to Medicare beneficiaries, and you cannot utilize an advance beneficiary notice (ABN) to seek payment.

Modifier indicators: Each PTP edit pair has a particular modifier indicator. This indicator can be “0,” “1,” or “9.” Take a look at what these indicators mean:

Indicator 0 — These codes should never be reported together by the same provider for the same beneficiary on the same date of service (DOS).
Indicator 1 — These codes may be reported together only in defined circumstances (identified on claims by specific CCI-associated modifier).
Indicator 9 — Not relevant. The edit was deleted.

Example: A PTP edit exists between codes 93015 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report) and 93005 (Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report). Code 93005 is a Column 2 code for 93015. However, since the modifier indicator for this PTP pair is “1,” you may use a CCI-associated modifier to override this edit under the appropriate circumstances.

Bottom line: So, when it comes to PTP edit pairs, the Column 1 code is payable, and the Column 2 is a component code that is only payable if certain criteria are met, according to Dunphy.

Append CCI-Associated Modifiers Appropriately

Modifier 59 (Distinct procedural service) is probably the most well-know modifier when it comes to PTP edits. However, modifier 59 is also a widely abused modifier that some use just to bypass an edit, so make sure you use append this modifier appropriately, Dunphy said.

Also, documentation is key when you are using modifiers. The supporting documentation must satisfy the criteria required.

“Only use this modifier if it [modifier 59] best describes the circumstances,” Dunphy adds. You should never just use modifier 59 as a default modifier.

X{EPSU}modifiers: Modifiers XE (Separate encounter…), XS (Separate structure…), XP (Separate practitioner…), and XU (Unusual non-overlapping service…) are a subset of modifier 59, but they have not replaced modifier 59.

You should never report modifiers X{EPSU} together with modifier 59 on your claim, Dunphy said. You should just report one modifier or the other.

Here are some tips from Dunphy about appropriate use for modifiers 59 and X{EPSU}:

A different session or patient encounter, different procedure or surgery, different anatomical site, or separate injury or area of injury.
When the medical record documentation indicates two separate distinct procedures performed on the same day by the same physician.
When there is no other appropriate modifier to use.

On the other hand, you should never use modifiers 59 or X{EPSU}under the following circumstances:

If the code combination does not appear in the NCCI edits.
You should not append these modifiers to an evaluation and management (E/M) service performed on the same date. In that case, you should look to modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).
If the PTP edit has a modifier indicator of “0,” you cannot use a modifier to break the edit.
If the medical record documentation does not support the separate and distinct status, you cannot use a modifier.
If the provider performed the exact same procedure code twice on the same day, you should instead look to modifiers 76 (Repeat procedure or service by same physician or other qualified health care professional) or 77 (Repeat procedure by another physician or other qualified health care professional).