Neurosurgery Coding Alert

Learn when it's OK to unbundle and increase your reimbursement potential If you're reporting two or more distinct services, you can often legitimately override NCCI edits by applying the proper modifier, thus increasing reimbursement and the accuracy of the billing record. Must-Know Point 1: What Are NCCI Edits? NCCI edits are pairs of CPT or HCPCS Level II codes that Medicare (and many private payers) will not reimburse separately except under certain circumstances. Medicare applies the edits to services billed by the same provider for the same beneficiary on the same date of service, says Barbara Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a medical billing company in Brick, N.J. Example: The most recent edition of NCCI (version 10.2) includes edits pairing needle electromyography (EMG) (95860-95861 and 95867-95868) to spinal injections (64400-64530), among others. This would mean that under most circumstances, the neurosurgeon could not report EMG and spinal injections for the same patient on the same day and expect to receive reimbursement for both procedures. Point 2: What Does 'Mutually Exclusive'Mean? NCCI contains two types of edits: mutually exclusive and "column 1/column 2" (previously known as "comprehensive/component" edits). Mutually exclusive edits pair procedures or services that the physician could not reasonably perform at the same session on the same beneficiary, says Kelly Dennis, CPC, EFPM, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla.

As an example, NCCI lists 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) as mutually exclusive of 61313  (... intracerebral). The provider would not expect that the surgeon would perform both types of craniectomy on the same date for the same patient because they describe different, exclusive procedures. In theory, the surgeon could not perform an intracerebral hematoma removal without removing the subdural (at least at the same site), and therefore you should not report these procedures separately. If you were to report two mutually exclusive codes for the same patient during the same session, Medicare would reimburse only for the lesser-valued of the two procedures (in the case of 61312 and 61313, the payer would reimburse only 61312). Point 3: How Do 'Column 1/Column 2' Edits Differ? Column 1/Column 2 edits describe "bundled" procedures. That is, CMS considers the code listed in column 2 as the "lesser" service, which is included as a component of the more extensive, column 1 procedure, Cobuzzi says. Example: The NCCI contains an edit bundling 61535 (Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue [separate procedure]) to 61320 (Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial).

In this case, 61320 is the more extensive procedure, which includes the "lesser" [...]