cci edits for mod 80

sundaey

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hey everyone,
I was just wondering about something. If in the CCI edits, it says that a sx is not payable for an assist, would you still code it and bill it out just for the sake of billing, or is that considered incorrect billing?
I need to get info on this in black and white, please, any help would be great!
 

RebeccaWoodward*

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Personally speaking, I post our assistant surgery the same, across the board. This is the protocol/standards developed within our company. I have discovered some carriers will pay for an assistant surgery regardless of CCI edits. Some private payers include language in their provider contracts or provider manuals stating that they follow the NCCI edit guidelines while others use third-party software to edit their claims that use their own logic to determine payment. My rule of thumb...the AMA is your best bet for accurate guidelines and coding conventions.
 
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I agree. This is a good example of one of the differences in "coding" and "reimbursement" From a coding perspective, it is correct to code for services rendered, eg, the assistant.

From a reimbursement perspective, some carriers cover it and some don't. Some provider/payer contracts states you need to write off the assistant charges.
 

adwood68

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Food for thought...

I believe if we are going to throw CCI out the window we should at least take into consideration the very nature of the procedure before we assume it should be reported with an 80 modifier. Some procedures cannot be physically performed by two surgeons. Just because a procedure is listed in the operative report and an assistant surgeon was present it doesn't mean the assist actually assisted on all of the procedures described in the operative note. I would have a dialog with my surgeons before making the assumption that all procedures in their op reports should be billed as assist. Also if you go and look at the procedures that CCI excludes from modifier 80 you will see that many of them are merited for that exact reason.
 

mbort

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I believe if we are going to throw CCI out the window we should at least take into consideration the very nature of the procedure before we assume it should be reported with an 80 modifier. Some procedures cannot be physically performed by two surgeons. Just because a procedure is listed in the operative report and an assistant surgeon was present it doesn't mean the assist actually assisted on all of the procedures described in the operative note. I would have a dialog with my surgeons before making the assumption that all procedures in their op reports should be billed as assist. Also if you go and look at the procedures that CCI excludes from modifier 80 you will see that many of them are merited for that exact reason.
An "assist" merely means they assisted with the surgery..it doesnt mean that they had to "physically perform" it. The could be holding a retractor and its still an assist.

I agree with Rebecca and Claudia wholeheartedly. We bill/code all assists across the board regardless of the carrier..even Medicare!!
 
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