Optometry Coding & Billing Alert

Published on Tue Jul 12, 2016 PDF

Experts advise on the best way to collect when CCI comes calling.

Sometimes it seems like just as you’re gearing up your practice for maximum coding efficiency, something comes along and throws a wrench in the works. Such is the case with the latest version of the Correct Coding Initiative, which has launched several new bundles that are bound to impact optometry practices across the country.

Expect Denials for 99173, E/M Codes

CCI version 22.2, which went into effect on July 1, now bundles 99173 (Screening test of visual acuity, quantitative, bilateral) into the office-based E/M codes 99201-99215.

In addition, CCI now bundles 65760 (Keratomileusis), 65765 (Keratophakia), 65767 (Epikeratoplasty), and 65771 (Radial keratotomy) into 92025 (Computerized corneal topography, unilateral or bilateral, with interpretation and report).

All of the new edits referenced above have an indicator of “1.”

What this means: Typically, an indicator of “1” means that you can use a modifier to bypass the edits, particularly in cases when your documentation can prove that the bundled, or “column 2” service was a distinctly separate service. For instance, it would apply if you billed the column 1 code for the left eye and the column 2 code for the right eye. However, there’s more to separating the edits than just sticking a modifier on the column 2 code and moving on.

Investigate Before Modifying

If you come across a CCI edit that has a “1” indicator on it, your first step should be to perform a bit of research, says Linda R. Farrington, CPC, CPMA, CPC-I, CRC, owner of Medisense, a medical coding consulting firm.

“The first thing that I would do is to look at the guidelines and instructional notes in CPT both at the beginning of the section (there are six in CPT Category I codes), the subsection, and also any parenthetical instructions beneath the code itself,” Farrington says.

She also reminds practices that not all payers utilize CCI. “It was originally developed for use by Medicare but has been adopted for use by some commercial payers,” she says. “Some payers have created their own, unique bundling edits. So, depending on the payer, you would want to apply the bundling edits that they would be using to adjudicate the claim.”

Finally, she says, don’t just stick modifier 59 (Distinct procedural service) on the claim and send it in without reviewing the documentation. “According to CMS, modifier 59 is the modifier of last resort,” Farrington advises. “You would want to go and read what the NCCI manual has to say about correct use of a modifier in this case. This will provider general guidance.”

In black and white: CMS’s article on modifier 59 states, “Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass a procedure-to-procedure (PTP) edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.”

Therefore, review the documentation, determine whether the procedures are distinct and separately identifiable enough to report together, and then evaluate which modifier is the most appropriate—it may not be modifier 59 in every instance.

Determine E/M Component Before Using 25

In some situations, such as when the CCI bundles an E/M code such as 99213 into a procedure code such as 68200 (Subconjunctival injection), you’re probably prepared to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to separate the edits—and this may be your best route to payment—but check the rules first, Farrington says.

“If this is a Medicare patient, it is important to have a good understanding of the CCI rules regarding use of an E/M code with minor procedures that are found in at least a couple of places in the CCI Manual – in Chapter 1 and Chapter 11,” she notes. “It is very important to read the narratives for the chapters for the codes that you use most often. There you will find the logic behind the edits and additional instructional notes regarding modifier use, including modifier 25.”

Once you read the information and you’re confident that your E/M is separately identifiably and significant, then you can append modifier 25, assuming your documentation warrants it.

Resource: To read the CCI manual, visit https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/.