Ob-Gyn Coding Alert

NCCI 27.0:

New Edits Target Your New Female Intraurethral Valve-Pump, Cervix Uteri Mapping Codes

Here’s why you need to pay attention to the modifier indicators.

Have you been receiving denials for your new T codes and 57465? The culprit may be the latest round of National Correct Coding Initiative (NCCI) edits, which went into effect January 1. Here are the highlights you need to know.

Here are the 0596T, 0597T Edits You Need to Know

Most notably, the following T codes are bundled into all gynecology and obstetric codes with either a “1” or “0” modifier indicator.

  • 0596T (Temporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement)
  • 0597T (Temporary female intraurethral valve-pump (ie, voiding prosthesis); replacement).

You’ll need to pay attention to the modifier indicator, as this will decide whether you can report two codes together. A modifier indicator of “1” means you can use a modifier to separate the edit pair — but you’ll have to provide justification.

Key: “Before immediately appending modifier 59 (Distinct procedural service), always review the modifier lists for a more appropriate/specific modifier,” says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department. “It is extremely important to use the X{EPSU} modifiers accordingly.” These modifiers include:

  • XE (Separate encounter…) describes a service that is distinct because it occurred during a different patient encounter.
  • XP (Separate practitioner…) describes a service that is distinct because it was performed by a different healthcare provider.
  • XS (Separate structure…) describes a service that is distinct because it was performed on a different anatomic site.
  • XU (Unusual non-overlapping service…) describes a service that is distinct because it does not overlap with the usual components of the main service.

No modifiers here: The 0596T/0597T edit pair list including a “0” modifier indicator is shorter, but still long: 57000-57010, 57065, 57106-57120, 57135, 57200-57250, 57265, 57268-57280, 57284, 57288-57289, 57300-57307, 57310, 57520-57530, 57540-57556, 57700-57720, 58120, 58145, 58150-58275, and 58285-58294. This means you can never report these codes with 0596T/0597T for any circumstances.

Remember: “Category III ‘T’ codes are created for emerging technology and act as tracking codes to help determine how often a particular service or procedure may be utilized in the future,” explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook. It’s important to keep in mind that reimbursement for these services varies among payers. Hence, there are no relative value units (RVUs) or Medicare Physician Fee Schedules (MPFSs) associated with these codes.

“When applicable, you should bill for a Category III code in place of an existing Category I code so long as the code description aligns with the surgeon’s work. Category III codes will remain in their respective section of the CPT® code book for up to five years before either being removed or converted to a Category I code,” adds Ferragamo.

These Edits Follow CPT® Guidelines

And per CPT® guidelines, prolonged services codes +99354-+99359 are bundled with a “0” modifier indicator into E/M office codes 99202-99205 and 99212-99215. That means you will never report one of these prolonged services codes with an E/M office visit.

This follows the notation in the CPT® descriptor. For instance, +99354’s descriptor states, “Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215])” (emphasis added).

Check Out New Code 57465’s New Edits

And finally, new code +57465 (Computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect (List separately in addition to code for primary procedure)) has been assigned many bundling edits.

For instance, you should think twice before reporting this code with 12001-12007 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet) …). NCCI gives a rationale for this edit of “misuse of column two with column one code” and assigns a modifier indicator of “1.” This means you could apply a modifier if you have supporting documentation.

Similarly, with the “1” modifier indicator, you will see the following services/procedures included in +57465’s column 2 edits: the integumentary codes for all levels of repair (simple, intermediate and complex), as well as codes for venipuncture, arterial puncture, insertion of bladder catheter, EKG and EEG, some pulmonary and ophthalmology services, established patient E/M services, critical and inpatient hospital services and the like.

The list of column 2 codes with a modifier indicator of “0” is shorter, but includes collection of a blood specimen via an implanted device, and all of the regional anesthesia codes and the moderate sedation codes.