Ob-Gyn Coding Alert

New bundles under the National Correct Coding Initiative (NCCI) mean you won't be able to report epidural administration and other regional blocks during labor management with maternity codes.

NCCI Edits , version 9.2, went into effect July 1. "Although the number of edits that will impact ob-gyn practices is not extensive, most of them represent services that Medicare will never pay for when billed together payment indicator '0' but the maternity code bundles may have far-reaching implications for obstetricians," says Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Fredericksburg, Va.

Labor and Delivery Include Epidurals

NCCI 9.2 continues CMS' bundling of anesthetic codes. Prior to this version, several bundles appeared for epidural anesthesia, but you could bypass these bundled codes using an appropriate modifier if the documentation supported it, Witt says. With version 9.2, CMS has added four regional block procedures to almost all of the Maternity Care and Delivery codes beginning with 59100 (Hysterotomy, abdominal [e.g., for hydatidiform mole, abortion]). The difference this time is that you cannot bypass these bundles with a modifier, she points out. The four bundled procedures are the following:
 

 62311 Injection, single (not via indwelling    catheter), not including neurolytic substances, with or   without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other salutation), epidural or    subarachnoid; lumbar, sacral (caudal)
 

 64430* Injection, anesthetic agent; pudendal nerve
 

 64435* Injection, anesthetic agent; paracervical (uterine) nerve
 

 64483 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level.

Bone Density Studies Are Now Mutually Exclusive

There are only a few new "mutually exclusive" code edits in NCCI 9.2, mostly associated with bone density studies. If you bill mutually exclusive codes for the same patient on the same date, Medicare and many other carriers will only pay the code with the lower reimbursement value, says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. This relationship does not appear to apply to the medicine-procedure code bundles. For this version, you can override only two of the mutually exclusive bundles for the comprehensive code 78350 with a modifier, she adds. The bundles are as follows: (please see the first chart at the top of this article)

Watch for 24 New Edits

Despite the relatively few new mutually exclusive edits, version 9.2 includes 24 new surgical comprehensive/component edits that will impact ob-gyn practices, Witt says. Medicare and those payers that follow NCCI will never pay all but three of these edits when you bill the codes together with a modifier.

The new surgical bundles that allow you to use a modifier to bypass the edit meaning they have a "1" modifier indicator under NCCI are: (please see the second chart at top of this article)

The bundles that will never be paid affect code combinations billed with colposcopy, trachelectomy and vaginal hysterectomy. These edits have a "0" modifier indicator, Mulholland says, meaning they will not be paid under any circumstance: 

 You can no longer bill 57500 (cervical biopsy), 57800 (dilation of cervical canal) and 58100 (endometrial biopsy) with the following vaginal and cervical colposcopy codes: 57421 (vaginal colposcopy with biopsy[s]), 57455 (cervical colposcopy with biopsy[s]), 57456 (cervical colposcopy with ECC) or 57461 (cervical colposcopy with LEEP conization).
 

 Don't report the colposcopy procedures 57421, 57455, 57456 and 57461 in addition to a trachelectomy (57530).
 

 NCCI now considers vaginal colposcopy (57420) to be an integral part of a vaginal hysterectomy, if performed, and Medicare will not pay for it when billed with codes 58260-58270 (vaginal hysterectomy procedures for a uterus that is 250 grams or less).

There have also been changes to existing code bundles for the following comprehensive codes: (please see the third chart at the top of this article)

Tie Up a Few Loose Ends

Medicare has permanently bundled three tissue ablation codes (76362, 76394 and 76490) into the Category III code 0009T (Endometrial cryoablation with ultrasonic guidance). For those physicians performing pulsed magnetic neuromodulation for incontinence, NCCI now bundles 97530 (Therapeutic activities, direct [one-on-one] patient contact by the provider [use of dynamic activities to improve functional performance], each 15 minutes) and 97533 (Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct [one-on-one] patient contact by the provider, each 15 minutes), but if the documentation shows they are separate, you can use a modifier to bypass the edit.

And version 9.2 includes 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) in ultrasound guidance for needle placement, but you can append a modifier to bypass the edit when indicated.