Pathology/Lab Coding Alert

Due to a large number of errors, the implementation of the national Correct Coding Initiative (CCI) version 6.1 has been delayed from April 1 to May 1, 2000. Users of any CCI edit products should make certain that they have a corrected copy of version 6.1 before its implementation on May 1, either in the form of an errata sheet or, in some cases, an updated book, says Laurie Castillo, MA, CPC, president of American Association of Professional Coders Northern Virginia Chapter and owner of Physician Coding & Compliance Consulting in Manassas, Va.

The National Technical Information Service (NTIS) publishes the CCI Edits , along with several other commercial resellers who purchase the raw data from NTIS. According to NTIS, all of its customers received an errata sheet soon after NTIS was made aware of the errors by the Health Care Financing Administration (HCFA).

We received 37 pages of changes from NTIS, confirms Tony Mistretta of the Medical Management Institute, one of the licensed resellers of the CCI edits. We have committed to making all the changes to the book by hand and sending out corrected manuals to our subscribers, he said.

Those who purchased CCI edits from a source other than NTIS and the Medical Management Institute also should look for corrections to version 6.1 in time for the May 1 implementation. For NTIS customers, this has been sent out in the form of an appendix, which must be cross-referenced to the version 6.1 product. Other resellers should have received the errata sheet from NTIS and made arrangements to get that information to their customers.

In response to direction from Congress, CCI edits were initiated in 1996 to reduce Medicare program expenditures by detecting inappropriate coding on claims, and denying payment. The CCI edits are basically a list of code pairs that Medicare will not reimburse together for the same patient on the same day, because they represent services that are bundled or would not ordinarily be performed together, states Castillo. Reporting two of these codes together for the same service represents fraudulent unbundling, which is the practice of breaking down a single procedure into its component parts, and billing for additional services, Castillo warns.

There are times, however, when two of these codes might legitimately be coded together, if they represent two services that are distinct and independent from each other, declares Castillo. In order to indicate that the codes represent separate services as opposed to unbundling of a single service, coders should use appropriate modifiers, such as CPT modifier -59 (distinct procedural service), she advises.

Correct Coding Modifier 0 and 1

The CCI edits list code pairs that are excluded based on two relationships: 1) One code is comprehensive and includes the service of the other, component code, or 2) The two codes are mutually exclusive, such as two different lab tests that measure the same factor.

Within the list of code pairs in the CCI edits, you will notice the use of superscript numbers 0 or 1 on some codes, says Castillo A 0 means that a modifier would not be appropriate to allow that code pair to be reported together under any circumstances, she continues. For example, two Pap smears using different cytopathology methods would not be carried out for the same patient on the same day. That is why code 88142 (cytopathology, cervical or vaginal automated thin layer preparation) is mutually exclusive with 88164 (cytopathology, slides, cervical or vaginal).

A 1 means that a modifier is allowed, if appropriate, says Castillo. For example, codes 88170 (fine needle aspiration; superficial tissue) and 88171 (fine needle aspiration; deep tissue under radiologic guidance) are considered bundled. If a patient has a radiologically located fine needle aspiration (FNA) of a deep breast lesion (88172) and also has a superficial lymph node aspirated (88170) on the same day, however, these would represent two separate, distinct services. As such, both codes could be reimbursable when reported with modifier -59. In fact, for any code pairs listed with a 1, Medicare requires the use of a modifier if the same physician reports them together for the same patient, on the same day.

The errors in the initial release of CCI version 6.1 involved the incorrect assignment of the 0 or 1modifier to 3,782 code pairs, says Mistretta. The vast majority (3,727 code pairs) were incorrectly assigned the 0, he continues, indicating that a modifier cannot be used to identify the services as separate and distinct. Using the uncorrected version 6.1, providers would not be allowed to bill these codes together, potentially causing significant under-reimbursement of legitimate services.

For pathology, many of the version 6.1 CCI edits involve the new lab panel codes in CPT 2000, which were implemented on April 1. The new codes, 80048 (basic metabolic panel), 80053 (comprehensive metabolic panel), 80069 (renal function panel), 80074 (acute hepatitis panel) and 80076 (hepatic function panel) are bundled with their component test codes. Fortunately for pathology, none of the comprehensive or component errors were in the 80048-80090 range of codes, reports Mistretta.

What To Do

The key to unraveling this situation is to make sure you are using the same CCI edits version 6.1 as your local Medicare carrier, says Castillo. Be on the lookout for the corrections and talk to your carrier to be sure you are using the same information, she advises. If you do that, hopefully the corrected errors will prove to be no more than an inconvenience until version 6.2 is released and implemented on July 1, 2000.