Wiki Need help with bundling

[tosuzz321]

Can anyone help me understand the CMS NCCI edits. I understand that I can bill column 1 and column 2 together with modifier/policy indicator of 1 but what if the code I am trying to find is not in the list such as 29826 and 29824? Or 29827 with 29826, 29824, 29822.. I really need some help here. Please and Thank you

 

[sls314]

Can anyone help me understand the CMS NCCI edits. I understand that I can bill column 1 and column 2 together with modifier/policy indicator of 1 but what if the code I am trying to find is not in the list such as 29826 and 29824? Or 29827 with 29826, 29824, 29822.. I really need some help here. Please and Thank you

The NCCI spreadsheets only include code pairs with an NCCI edit - it isn't a comprehensive list of all potential code pairs that could exist. If a pair of CPT codes doesn't have an edit between them, it won't be on the NCCI spreadsheet.

BTW - there is an edit between 29827 and 29822. There's also an edit between 29824 and 29822. (I only point that out because you mentioned those codes together above.)

 

[podcoder70]

The column 1/column 2 correct coding edit table contains two types of code pair edits. One type contains a column 2 (component) code which is an integral part of the column 1 (comprehensive) code. If two codes of a code pair edit are billed by the same provider for the same beneficiary for the same date of service without an appropriate modifier, the column 1 code, which generally represents the major procedure with greater work relative value units (RVU) of the two codes, is paid. If clinical circumstances justify appending a CCI-associated modifier to the column 2 code of a code pair edit, payment of both codes may be allowed.

In other words, if your 2 code combo has an indicator "1" it means that, when appropriate, they can be billed together with appropriate modifier, ie: 59. The key words are "when appropriate". The modifier will get them paid, however, are they legitimately a distinct procedure? There are a lot of code combos that are inclusive of the other and have an indicator 1. Some codes bundle together thus making it only possible to use the combo when performed on different anatomical sites. In answer to your second question, if there are no CCI edits, no modifier is required to distinguish one from the other. With that said, I have found that many payers still expect a 59 modifier on the lower RVU code.

 

[amyjph]

I would add that because you listed those specific codes, it's not just the edits to take into consideration. You also have to understand the NCCI manual.
Example as you mentioned above: 29827 and 29822 have an edit, it says a modifier "may be allowed" however, you can't just slap a 59 or X-mod on there. The manual tells you why. "7. Shoulder arthroscopy procedures include limited debridement (e.g., CPT code 29822) even if the limited debridement is performed in a different area of the same shoulder than the other procedure" https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-4.pdf

Check this link where we discussed recently: https://www.aapc.com/discuss/threads/need-help-with-shoulder-surgery.191008/?view=date#post-523156

When talking 29826 you also have to consider the payers such as Anthem who find this is investigational and won't pay for SAD.
Some more fun shoulder talk: https://www.aapc.com/discuss/threads/29823-or-29826.189091/?view=date#post-517511

Side note - if the payer goes by McKesson there are some differences between those edits and NCCI. Rare, but happens and I think there is specifically one in shoulder scopes, but I can't think of which it is at the moment.