ED Coding and Reimbursement Alert

Crack down on incorrect unbundling

The National Correct Coding Initiative (NCCI) has been at it again with updated edits for this quarter. NCCI volume 12.0 introduces a startling 59,080 new column 1/column 2 edits and 465 new mutually exclusive edits, and many of these code bundles could warrant a modifier 59 to optimize reimbursement.

But watch out--in a recent sampling, the U.S. Office of Inspector General (OIG) found over $59 million in overpayments to providers due to the misuse of modifier 59 (Distinct procedural service). This leaves your carrier no choice but to scrutinize your practice's NCCI savvy and modifier 59 usages like never before. How It Works  There are two types of NCCI edits: -column 1/column 2- and -mutually exclusive.- A column 1/column 2 NCCI edit is where one code (in column 1) comprehensively includes another code (in column 2), so you can't bill both under normal circumstances. Mutually exclusive NCCI edits are procedures that wouldn't normally be billed on the same day.

The good news: In the right cases, you may be able to override these bundles with the proper application of a modifier. Here's how: 1. Use 59 When Services Are Separate and Distinct Modifier 59 isn't just a ticket to increase your reimbursement. Use it to -- identify procedures/services that are not normally reported together but are appropriate under the circumstances,- states the Centers for Medicare & Medicaid Services (CMS) in an article on its Web site.

These situations may include a different session or different patient encounter, a different procedure or surgery, a different site or organ system, or a separate incision/excision, not ordinarily encountered or performed on the same day by the same physician.

To read the full CMS article, visit www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf. 2. Know When NOT to Use 59 This modifier does not automatically unbundle all NCCI edits. The edits have a column that notes with a -1- or -0- whether a modifier is -allowed- or -not allowed.- You-re in the clear to unbundle the separate and distinct procedures if the edits list a -1,- but you-re out of luck if you try to do this when you see a -0.-

Next step: Don't put in modifier 59 on autopilot when you see a -1.- The edits still don't specify which modifier to use, or if a modifier even qualifies for your situation, says Denise Paige, CPC, president of the AAPC Long Beach Chapter in Long Beach, Calif. You may also have to use an anatomical modifier such as RT (Right) or LT (Left), Paige says.

Careful: RT and LT don't always pay, so check with your payers to see which modifiers they prefer for certain NCCI edits. 3. Append 59 to the Correct Code [...]