Radiology Coding Alert

Due to a large number of errors, the implementation of the National Correct Coding Initiative (CCI) version 6.1 was 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, 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 an NTIS spokesperson, all of their customers, including subscribers and resellers such as Medical Management Institute, Medicode and St. Anthonys, received an errata sheet soon after the Health Care Financing Administration (HCFA) made NTIS aware of the errors.

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 committed to making all the changes to the book by hand, and sending out corrected manuals to our subscribers.

Those who purchased CCI edits from another source should also confirm that they have received corrections to version 6.1. 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.

Background

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.

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).

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. A 1 means that a modifier is allowed, if appropriate.

For example, codes 88170 (fine needle aspiration ; superficial tissue) and 88171 (fine needle aspiration; deep tissue under radiologic guidance) are considered bundled. If, however, a patient has a radiologically located FNA of a deep breast lesion (88171) and also has a superficial lymph node aspirated (88170) on the same day, 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 1 modifier to 3,782 code pairs, says Mistretta. The vast majority (3,727 code pairs) was incorrectly assigned the 0, 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.


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. Double-check that you have copies of the corrections and that all those in your office who are affected know how to implement the corrections correctly. In addition, it is advisable to talk with your carrier to be sure you are using the same information.

If coding professionals follow these steps, the corrected errors will likely prove to be no more than an inconvenience until version 6.2 is released and implemented on July 1, 2000.