Gastroenterology Coding Alert

Question: How do I know if I can -unbundle- NCCI edits? Do I need to use a modifier?


Georgia Subscriber

Answer: Each National Correct Coding Initiative code-pair edit includes a correct coding modifier indicator of 0 or 1.

A -0- indicator means that you may not unbundle the edit combination under any circumstances, according to NCCI guidelines.

An indicator of -1- means that you may use a modifier to override the edit if the procedures are distinct from one another. You should only attempt to override NCCI code-pair edits if the paired procedures are separate and unrelated, however. For instance, the physician may have provided the services/procedures at different sessions, at different anatomic locations, or for different diagnoses.

Example: The gastroenterologist performs a colonoscopy. In the cecum he finds a polyp, which he removes by snare technique (45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). While investigating the transverse colon, the physician locates a suspicious area, which he injects with India ink (45381, ... with directed submucosal injection[s], any substance). Because the endoscopic procedures occur at different anatomic locations, you may report them independently.

To indicate that the polyp removal and India-ink injection were separate procedures in separate areas, you must append modifier 59 (Distinct procedural service) to the -column 2- (lesser-valued) code. In this example, you should report 45385--because it is the higher-valued code--and append modifier 59 to 45381.