Use CCI Edits to Determine When to Use Modifier -59
Published on Tue May 01, 2001
When part of a claim containing a combination of codes is denied by Medicare, gastroenterologists and members of their coding staff often wonder if they might have gotten more reimbursement by adding modifier -59 (distinct procedural service) to one of the codes. Some of the guesswork surrounding this modifier can be eliminated by studying HCFAs national Correct Coding Initiative (CCI), which uses a system of superscripts to indicate which coding combinations could be separately reimbursable under certain circumstances if modifier -59 is attached to the proper code.
The CCI is a set of published edits or computer instructions to help Medicare payers identify improper claims. The CCI edits, which are published quarterly, give payers and providers more direction on how to bill certain coding combinations, according to Pat Stout, CMC, CPT, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn.
While the American Medical Associations CPT manual is a good, comprehensive collection of codes and their descriptions, it doesnt give providers any guidance on how to report multiple procedures, she notes.
Unfortunately, busy gastroenterology practices often overlook important information in the CCI. Everyone should review the latest edits as soon as they come out, says Albert Shaw, practice manager at Asher, Kornbluth MDPC, a three-physician gastroenterology practice in New York City. Most people wait three or four weeks; then claims start getting bounced by Medicare. When they try to figure out what has happened, its usually Oh, there was a new CCI edit.
Two Types of CCI Edits
Two lists of edits in the CCI should be reviewed regularly by gastroenterology practices the mutually exclusive edits and the comprehensive/component edits.
Mutually Exclusive Edits: The list of mutually exclusive edits contains coding combinations that HCFA believes cannot reasonably be done in the same session. An example of a mutually exclusive coding combination from the digestive section of the CCI is HCPCS code G0105 (colorectal cancer screening; colonoscopy on individual at high risk) and CPT code 45378 (diagnostic colonoscopy). A gastroenterologist would not perform a screening colonoscopy and a diagnostic one in the same session, explains Stout, who adds that only one of those codes would normally be reported on the medical claim.
Another, more controversial mutually exclusive edit is 43268 (ERCP; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) and 43269 (ERCP; with endoscopic retrograde removal of foreign body and/or change of tube or stent), which might be used to report the endoscopic change of biliary stents. Private payers might accept both codes, Stout says, because CPT guidelines say both codes should be reported. An article in the spring 1994 CPT Assistant states that if a stent [...]
