Question 63650 new CCI edit for 2019 with 95972

betsycpcp

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As of 1/1/19 NCCI shows 95972 in column 2 so that it bundles with 63650. It says reason is "CPT Manual or CMS manual coding instructions" but I can't find anything in the NCCI Policy Manual or the Medicare Claims Processing Manual about it. I don't have a hard copy of the 2019 CPT manual but I checked Optum Encoder Pro and Revenue Cycle Pro, and can't find anything at all showing CPT manual instructions or Medicare instructions explaining this edit.

I work for a payer and a provider is questioning our denial. They used modifier 59, but the documentation needs to support that. However with no explanation of why there is an edit all of a sudden for 2019, I don't know what does or does not justify billing with modifier 59.

I tried searching on Google and got absolutely nothing. Has anyone run into this and do you know that the rationale is?

Thanks in advance for any insight. If you have a reference from some official source please let me know what that is and/or quote it if you can.
 

CodingKing

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You will need the full AMA CPT code book guidelines pages. The guidelines were expanded greatly eff 1/1/19 along with code description changes.

Due to copyright i cant paste. But generally it says:

Test stimulation during implantation is not considered electronic analysis or programming of the neurostimulator and should not be reported separately.
 

betsycpcp

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The software we have does include the wording you mentioned but they have the guidelines for the entire sections jumbled together on one page so it's hard to compare it to the 2018 manual (which I do have a hard copy of). But after looking them over it looks like the key is verifying that they were programming the stimulator and not just doing test stimulations. I did see those instructions before but I didn't see that as a bundling issue- more of a correct coding issue. However that does seem to be the source of the new edits.

Thank you so much- that really helps!
 
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