Advanced Search

Pulmonology Coding Alert

Review CCI Edits Quarterly to Stay on Top of Changes

Published on Fri Feb 01, 2002

The Correct Coding Initiative (CCI) version 8.0, effective Jan. 1 through March 31, 2002, does not affect pulmonology practices. The absence of changes, however, does not mean that coders should neglect their quarterly review. Failure to regularly review the edits can mean incorrectly billed procedures, risking allegations of improper billing by Medicare, or inadequate reimbursement.

What CCI Edits Contain

The CCI edits released by CMS contain two categories of edits. The first category includes comprehensive and component codes, which identifies codes bundled into their more comprehensive procedures. Procedures that are bundled cannot be billed separately.
 
An example of this is comprehensive code 31630 (bronchoscopy; with tracheal or bronchial dilation or closed reduction of fracture) billed with 31622 (diagnostic bronchoscopy). In this case, CCI requires that to perform therapeutic or surgical bronchoscopy with intervention performed, you must perform a diagnostic bronchoscopy first. Therefore, 31622 (the diagnostic procedure) would not have been unbundled from 31630 (the comprehensive procedure).
 
The second category contains mutually exclusive codes that list code pairs not typically reported together during the same session on the same date. For example, a bronchoscopy with initial aspiration (31645) is mutually exclusive of a bronchoscopy with subsequent aspiration of the bronchial tree (31646). A physician typically does not do the initial and subsequent aspiration in the same session.
 
CCI edits also have superscripts of "1" or "0," which are included with each code pair. If a code pair has a superscript of "1," it can be overridden, if necessary, with modifier -59 (distinct procedural service). A code pair with a superscript of "0" means it cannot be overridden. For example, 94656 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day) and 94657 ( subsequent days) have a "0" superscript because they cannot be reported on the same day.

Interpreting Modifier -59

When modifier -59 is appended to a CPT code, a separate or distinct procedure or service is being reported from the first service. Separate and distinct indicates the procedure can be performed at a separate session or different site.
 
An example of this is reporting 31628 (bronchoscopy; with transbronchial lung biopsy, with or without fluoroscopic guidance) with 31625 (endoscopy; with biopsy). If these two procedures are performed at separate sites or locations, modifier -59 is appended to 31625 and a claim is submitted requesting payment for 31628 and 31625.
 
To identify the two separate biopsy sites, use separate diagnosis codes. For example, use 786.6 (swelling, mass, or lump in chest) to indicate a right upper lobe mass with 31628-59. If 31625 is performed for a left lower lobe nodule, report 31625-59 with a diagnosis of 518.89 (other diseases of lung, not elsewhere classified).
 
"We tried to override the edit with modifier -59 because we had two separate lesions we were biopsying through two different methods," says Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the department of medicine, University of Pennsylvania. "If you fail to add modifier -59 when appropriate, it will not override the edit. If you attach it when there is a superscript of 0, it also will not override the edit. If you are reporting a bundled code pair together, the claim will be denied."
 
If a claim is denied, a new claim can be submitted. A denial could result if modifier -59 was not appended to the code pair that had a superscript of 1. If it is appropriate to report the two procedures together, resubmit the code pair with modifier-59 and request payment.
 
Note: To subscribe to the latest CCI edits, call the National Technical Information Service at 1-800-363-2068 or 1-703-605-6060.

Other Articles in this issue of

Pulmonology Coding Alert

View All