Orthopedic Coding Alert

The new edition of NCCI targets surgical codes

With more than 9,000 changes in the latest National Correct Coding Initiative quarterly update (version 13.0, effective Jan. 1), you could spend an entire month trying to determine how the edits will affect your orthopedic surgery practice.

Or you could simply look below for the most important additions and deletions.

NCCI Affects New Spine Codes

The new edition of NCCI bundles 69 codes into the new percutaneous intradiscal electrothermal annuloplasty codes 22526 (Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level) and +22527 (... one or more additional levels [list separately in addition to code for primary procedure]).

For example, you can no longer bill spinal surgery codes 62270, 62287, 62290-62291, 62310-62319 and discography codes 72285 and 72295 with the new codes in the 22526-22527 range.

But hopefully this shouldn't affect many practices, because you may have expected these bundles. -The discography codes seem to be an integral part of the annuloplasty procedure, so no, this doesn't surprise me,- says Denise Paige, CPC, coding and billing manager at Beach Orthopedic Associates in Long Beach, Calif., and the president-elect of the AAPC's Long Beach Chapter.

Arthroplasty targeted: The NCCI also created over 40 new component codes that will now be bundled into the new total disc arthroplasty codes 22857-22865.

Among the procedure codes that are now bundled into these codes are other arthrodesis codes, spinal instrumentation codes, laparotomy codes, needle electromyography codes, nerve conduction study codes, an intraoperative neurophysiology code (95920), and evoked potentials and reflex test codes (95925-95937).

-This isn't a big surprise, either,- Paige says. -It seems, despite what the vendors say, that most of the intraoperative imaging and sensory tests seem to be bundled and not separately payable.-

As far as the instrumentation being included in the total disc arthroplasty, -it also seems to be the trend to lump everything into one code (the laminoplasty codes are one example), which makes it easier to code, but payment-wise it may not be so beneficial,- Paige says. -But then when you look at the multiple procedure/payment rules that most carriers have, it may end up the same whether it's one code or several.-

NCCI Also Targets Radial Fracture, Tendon Codes

Practices that were excited to get a new tendon excision code (25109, Excision of tendon, forearm and/or wrist, flexor or extensor, each) may be surprised to see that they can no longer bill debridement codes 11010-11012, elbow manipulation code 24300, tendon surgery codes 25000-25001 and 25110, or wrist manipulation code 25259 with 25109, unless they can justify it with a modifier.

On the bright side, however, -the RVUs for 25109 include the component codes, so the edits are reasonable,- says Susan Vogelberger, CPC, CPC-H, CMBS, CCP, owner and president of Healthcare Consulting & Coding Education LLC in Boardman, Ohio. -For example,- she says, -manipulation and debridement are usually included in the main procedure.-

Look for radial fracture fixation edits: NCCI also targets the new radial fracture fixation codes 25606-25609, which will gain over 45 component codes. You cannot report several wound repair codes, fracture care codes, casting/splinting codes, neuroplasty and other surgical add-ons with the new radial fracture fixation codes unless you can justify adding a modifier.

-The RVUs attached to these codes include the component codes that are bundled, so the edits make sense to me,- Vogelberger says. -There really won't be many times that you will want to bypass the edits with amodifier, unless you are indicating a different site. For example, when you perform a procedure on a joint, manipulation is always included in that procedure, unless it's a different joint.-

Stick with the tendon repair bundles: Coders may recall that CPT Codes 2007 removed the words -separate procedure- from the descriptors of tendon repair codes 26170-26180. Now that the descriptors have changed, the NCCI stepped in and bundled other tendon repair codes into these hand surgery codes. However, you can use a
modifier if the surgeon addresses different tendons at separate sites. 

Prepare for Medically Unlikely Edits

Coders have heard rumors for several years about -medically unbelievable- or -medically unlikely- edits, but this time, CMS has gone ahead and instituted the new medically unlikely edits.

Effective for dates of service on or after Jan. 1, 2007, you-ll have to contend with the MUEs, which are separate from the already-established NCCI edits -- but if the edits function as intended, you should find them more a help than a hindrance to your practice.

Bone Up on the New MUEs

The goal: The new edits are designed to prevent overpayments caused by gross billing errors, usually as the result of clerical or billing system mistakes, said Niles Rosen, medical director for Correct Coding Solutions, which has worked with CMS to develop the current edits, during a presentation at the American Medical Association's CPT and RBRVS 2007 Annual Symposium in Chicago.
 
What it means to you: -The MUEs will limit automatically the number of units of service you can bill for a service in any 24-hour period,- Rosen said.
 
Learn Anatomical Edits First

The first batch of MUEs will focus on anatomically impossible claims, and CMS will phase in other edits over time.

For example: The MUEs would limit the number of simple repair codes (12001-12021) per anatomic location that you may bill per claim. For instance, you would never code for simple repairs of the hand using both 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) and 12004 (... 7.6 to 12.5 cm) for the same patient during the same session. Instead, you would add the lengths of the various repairs and report a single unit of service, such as 12005 (... 12.6 to 20.0 cm).

Also, the edits will limit the claims for 99304 (Initial nursing facility care, per day ...) to a single unit per calendar day. This makes sense because 99304 is a -per day- code, experts say.

Appeal MUE Denials in These Cases

One advantage of the MUEs is that if you do run afoul of the edits, you won't face denial for your entire claim, but only the single line item that violates the MUE guidelines, Rosen said.

In addition, you will be able to appeal MUE edit rejections if you think your claim meets the requirements of medical necessity

Bonus: -We have designed the edits such that there should be an absolute minimum of inappropriately rejected claims. The criteria we use are meant to catch egregious errors, not to prevent legitimate services from being paid,- Rosen said.

Updates: Like the NCCI edits, MUEs will be updated quarterly and be subject to continuing refinement.

For more information on the MUEs, visit www.cms.hhs.gov/MLNMattersArticles/downloads/MM5402.pdf.