ED Coding and Reimbursement Alert

Question: I heard that HCFA has suspended the 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 probably wont reinstate any of these until July 2001. Most significant about the 6.3 edits was the bundling of evaluation and management (E/M) services with diagnostic procedures, says Barbara Cobuzzi, CPC, CHBME, president of Cash Flow Solutions Inc. in Lakewood, N.J. She says 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.

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.

The edits bundled critical care (99291, 99292) as a component of 36010 (introduction of catheter, superior or inferior vena cava). Now, with the edit suspension, you can resubmit previously denied claims for this service by attaching modifier -25.

HCFA has pledged to work with the AMA and other medical societies to continue educating providers in how to append modifier -25 to E/M services when billed with procedures performed on the same day. The work of the E/M procedure is significant and separate from work that is inherent in the primary procedures, HCFA says. This is correct coding and should be practiced regardless of any edits HCFA might implement in the future.

Before reinstating any of the suspended edits, HCFA says it will develop a program of carrier guidance and education and provide directions for carriers to publish information in their newsletters. The agency will also look at clarifying the criteria for a significant and separate service and consider implementing a national policy that would allow providers to use one diagnosis code for an E/M service and procedure performed on the same patient on the same day.