Ob-Gyn Coding Alert

Question: I used the Correct Coding Initiative (CCI) edits checker tool and entered 2 CPT^® codes (58558 and 58559). There was no indication these codes cannot be reported together. However, when I use the CMS scrubber tool and enter the codes, I get a “critical” error message indicating the code cannot be reported, per CPT^® relationship guidelines. I’m confused on what’s going on here.

Codify Subscriber

Answer: The CCI edits were initially developed by CMS to capture code pairs that practices were incorrectly coding together. They determined this list by first identifying all codes that were paired at least 5% of the time, and then they examined each pair to decide whether to keep the edit or reject it. They base their rules on a combination of things.

Good idea: You should go to the following link to download the CMS CCI procedure manual and especially look at Chapter 1 which details all of the bundling rules and why the bundles exist: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.  In a nutshell, while they use the instructions in the CPT^® book for some of their edits, they also create edits because codes are:

• standards of medical/surgical care (such as the surgical approach, removing adhesions, controlling bleeding, putting in catheters),
• gender specific,
• mutually exclusive (like doing a vaginal and abdominal hysterectomy at the same session), have a more extensive code (like reporting a TAH with nodes instead of itemizing the TAH and nodes separately),
• belong to a family of codes so that only one should be reported,
• are CPT^® "separate" procedures, or 
• are sequential procedures (you start with one approach and convert to a new approach so you only bill the finalapproach).

In your example, the bundled code is for lysis of adhesions (58559, Hysteroscopy, surgical; with lysis of intrauterine adhesions [any method]), and would be bundled by many Medicare payers — even if CCI does not bundle this code with 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C). In fact, CMS has stated that their list is not all-inclusive.

Bottom line: When codes are billed together that meet their basic rules, they may be denied even though the CCI table may not list them.