NCCI vs CPT

mudlark1

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An insurance carrier is denying our 44005 as included in the 51500 performed at the same surgical session based upon the NCCI policy that codes designated as separate procedures are not payable unless performed through a separate incision, at a separate encounter etc. My question is does this supercede the NCCI edit that the 44005 is not a component of the 51500? Any insight is appreciated.
 

mitchellde

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The CPT designations for separate procedures stopped many years ago perhaps as long as 10 years or more ago. because it conflicted with the CCI edits which are updated quarterly. If you can download the official CCI edits and you have checked both component of comprehensive as well as mutually exclusive pairings and there is no conflict then I would make screen shots of this and make sure the quarter you are referencing cooresponds to the visit date, then send an appeal.
 

dclark7

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Sorry to disagree with you Debra, but the separate procedure designation is alive and well in CPT. Under the surgical Guidelines separate procedures are explained (page 54 in the CPT Professional Edition) and code 44005 is designated as a (separate procedure) in the CPT book. I'm not debating whether this code should be coverd in this particular instance, just pointing out that the designation still exists.
 

mitchellde

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I am sorry , my CPT book has no separate procedure designations any long and I have not had a book in years that does, I remember a notice from way back that stated the separate procedure designation was a thing of the past. However the code in question here 44005 is routinely bundled into every open procedure. I have always found this to be true in the CCI edits. If your book still has a separate procedure designation I am at a loss as to why they are different but it is not the first time I have encountered this with the code books. However even so , the designation of separate procedure does not prohibit the coding of two procedure it just follows the same logic as the CCI edits that you must support a separate site or incision or time of day. I apologise I was unaware of this difference in code books.
 
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CCI does NOT include separate procedures

CCI edits never include any of the "separate procedure" codes as bundled, yet they will ALL be considered as bundled unless they are a separate incision/ separate surgical site that legitimately takes a -59 modifier.

I use the Professional Edition of CPT published by the AMA and it definitely still includes "separate procedure" designation on 44005 and many other codes.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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