Eli's Rehab Report

Published on Mon Jul 10, 2006 PDF

Learn the 1 new physiatrist-related version 12.2 edit that could affect you

If you're still uncertain what a mutually exclusive edit is and whether you're using the latest NCCI version in your physical medicine and rehab practice, you could be setting yourself up for possible future reimbursement hassles.
 
Get a handle on the NCCI in's and out's by reading these six questions and the answers provided by our experts.

Question 1: What Are NCCI Edits?

National Correct Coding Initiative (NCCI) edits are pairs of CPT or HCPCS Level II codes that Medicare (and many private payers) will not reimburse separately except under certain circumstances. Medicare applies the edits to services billed by the same provider for the same beneficiary on the same service date, says Kelly Dennis, MBA, CPC, ACS-AP, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla.
  
Example: The most recent edition of NCCI (version 12.2), effective July 1, bundles the vast majority of E/M codes into Nursing Facility Care codes (99304-99306).
 
This means that your physiatrist may not be able to report an E/M code (such as 99203, Office or other outpatient visit for the evaluation and management of a new patient ...) and a nursing facility care code (such as 99304, Initial nursing facility care, per day, for the evaluation and management of a patient ...) for the same patient on the same day and expect to receive reimbursement for both services.

Question 2: What Does 'Mutually Exclusive' Mean?

NCCI contains two types of edits: mutually exclusive and comprehensive/component edits.
  
Mutually exclusive edits pair procedures or services that the physician would not reasonably perform at the same session, at the same anatomic location, on the same beneficiary, Dennis says.
 
Example: Thanks to an NCCI mutually exclusive edit, you may not be able to report 64483 (Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level) when your provider performs this procedure at the same session as 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution] epidural or subarachnoid; lumbar, sacral [caudal]).
 
If you were to report two mutually exclusive codes for the same patient during the same session, often the pairings are such that payers would process the procedure/service with the lower valuation. In this case, 62311 is the lower-valued procedure.

Question 3: Do 'Column 1/Column 2' Edits Differ?

Comprehensive/component edits describe bundled procedures/services. That is, CMS considers the code listed in column 2 as the lesser service, which is included as a component of the more extensive column 1 service.
 
Example: NCCI 12.2 bundles 29540 (Strapping; ankle and/or foot) into 20550 (Injections[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar "fascia"]). In this case, 20550 is the column 1 code -- the more extensive procedure -- which includes the column 2 code -- the lesser procedure (29540). If a provider performs a tendon sheath or ligament injection on the same day as the patient undergoes a strapping to her ankle or foot, you should only report the injection.
 
If you were to report bundled (column 1/column 2) procedures/services for the same patient during the same session, Medicare would reimburse only the column 1 code, which is typically the higher valued of the two procedures (in this case, 20550).

Question 4: Can I Ever Override NCCI Edits?

Yes, in certain circumstances you may override NCCI edits and achieve separate reimbursement for bundled codes.
  
Step 1: Check the correct coding modifier indicator. Each NCCI code-pair edit includes a correct coding modifier indicator of 0 or 1.
  
A 0 indicator means that you may not unbundle the edit combination under any circumstances, according to NCCI guidelines.
 
For example, the edit that bundles the orthotic checkout code (97762, Checkout for orthotic/prosthetic use, established patient, each 15 minutes) into 97755 (Assistive technology assessment [e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility], direct one-on-one contact by provider, with written report, each 15 minutes) has a modifier indicator of 0. Medicare and other payers that follow NCCI edits will always deny 97762 when you bill it with 97755.
 
An indicator of 1, however, means that you may use a modifier to override the edit if the procedures are distinct from one another (for instance, if they occur in separate anatomic locations or during different sessions).
  
Example: The new NCCI 12.2 edit that combines 29540 into 20550 has a 1 modifier indicator. To override this edit, your physiatrist would have to inject a different anatomic region than the one he straps or perform the two services during different patient visits on the same day.
  
Step 2: Append modifier to the correct code. You can append modifier 59 (Distinct procedural service) to the column 2 code to indicate to the payer that the billed procedures are distinct and separately identifiable, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.
 
So if your physiatrist provides an injection to a tendon sheath in the left wrist (20550) at the same encounter as he straps the left ankle (29540), you should append modifier 59 to 29540. The reason is that 29540 represents the column 2 or the lesser-procedure code.

Question 5: How Often Are the Edits Updated?

CMS updates NCCI every quarter, and you should always consult the most recent version when coding.
  
The number of changes each quarter varies, but almost every update contains significant changes. "You'll always want to be sure to be using the latest edition of NCCI," Cobuzzi says. "If you're one or two versions behind, you could be coding incorrectly and not even know it."

Question 6: How Can I Find the NCCI Edits?

You can stay up-to-date on NCCI changes two ways:
  
1. You can find NCCI updates through the CMS Web site www.cms.hhs.gov/physicians/cciedits/default.asp. The site contains a listing of the NCCI edits by specific CPT sections and is available free for downloading.
  
2. Or you may purchase a quarterly or yearly subscription to the NCCI from the National Technical Information Service (NTIS) Web site: www.ntis.gov/products/families/cci.