Part B Insider (Multispecialty) Coding Alert

Published on Tue May 17, 2011 PDF

Tip: Keep edits in mind for other payers besides Part B MACs.

With the new round of Correct Coding Initiative (CCI) edits going into effect as of July 1, it's a good time for a CCI refresher. Whether you're new to coding or you've been dealing with the edits for years, it can't hurt to check out the following three frequently-asked questions that subscribers send to the Insider.

Tip: Keep edits in mind for other payers besides Part B MACs.

With the new round of Correct Coding Initiative (CCI) edits going into effect as of July 1, it's a good time for a CCI refresher. Whether you're new to coding or you've been dealing with the edits for years, it can't hurt to check out the following three frequently-asked questions that subscribers send to the Insider.

Know When Modifiers Apply

Question 1: Our office manager never allows us to use a modifier to override the CCI edits because she says that ignoring CCI edits amounts to "unbundling," which is not appropriate. But we've been using modifiers to override CCI edits for years. Who is right?

Answer: In certain clinical circumstances you can override -- not ignore -- CCI edits and receive separate payment for bundled codes. To find out if you can separately bill services, first check the "modifier indicator" in column F of the CCI spreadsheet.

A "0" indicator means that you cannot unbundle the two codes under any circumstances. An indicator of "1," however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate payment.

Tip: The most common modifiers that Part B practices use to override an edit pair are 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when used with an associated E/M code, or modifier 59 (Distinct procedural service) when two non-E/M services are performed, but other modifiers may apply in some circumstances.

For instance: The CCI edits bundle nebulizer demonstration code 94664 into inhalation treatment code 94640. CCI, however, allows you to report a modifier to override this bundle when circumstances make separately reporting the education appropriate. If the education occurs while the patient is receiving the inhalation treatment, do not separately bill the education. However, if, for example, the doctor provides the inhalation treatment and subsequently performs the training, you may report 94664 with modifier 59 appended.

Do CCI Edits Only Apply to Part B?

Question 2: When we're billing a payer other than Medicare Part B, do we have to follow CCI edits, or are they Medicare-specific?

Answer: Although all Part B payers do follow the CCI edits, many other payers take them into account when determining which procedures should be paid separately.

Example: As part of the Affordable Care Act, state Medicaid programs were told to begin using CCI edits when processing claims as of Oct. 1, 2010. This means that you've probably seen CCI edits at work with some of your Medicaid claims. In addition, many private payers and workers''compensation insurers also use the CCI to justify claims payment and denials. You should check with your payers to determine which use the CCI edits and which do not.

Don't Bill Patients When Exceeding MUE Limits

Question 3: We've had several claims denied due to the medically unnecessary edits (MUEs) that CCI has been instituting. We've been billing the balance to the patient but our auditor is trying to discourage us from continuing to do that. Why would that be?

Answer: You aren't alone in your belief that patients can be balance billed for this, but you join many other practices in believing this common MUE myth. The reality is that even if you have the patient sign an advance beneficiary notice (ABN), you cannot pass on the cost of procedures you know will be denied due to MUEs.

CMS makes this rule very clear in its FAQs (http://questions.cms.hhs.gov), stating: "A provider/supplier may not issue an ABN for units of service in excess of an MUE. Furthermore, if services are denied based on an MUE, an ABN cannot be used to shift liability and bill the beneficiary for the denied services. It is a provider/ supplier liability."