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CCI Edits - I have a carrier disputing

  1. Default CCI Edits - I have a carrier disputing
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    I have a carrier disputing the use of modifiers according to Medicare CCI edits. Can someone give me input?

    We billed 99205,25 (New Pt E & M)
    96118 (Neuropsychological testing)

    According to CCI edits: column 1 99205 pairs with 96118 but allows a modifier

    We appended the modifier 25 on the E&M as a separate service from the "procedure".
    The carrier states this is incorrect and it should be billed as 99205, 96118,59 (using modifier 59 on the procedure).

    However, according to CCI edits, modifier 59 should not be used unless there are 2 procedures. CPT guidelines would dictate using modifier 25 in order to bill the E&M but the carrier states this is not consistent with the CCI edits. CCI edits aren't exclusive to modifer 59 are they?

  2. #2
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    Quote Originally Posted by catrina.thomas View Post
    I have a carrier disputing the use of modifiers according to Medicare CCI edits. Can someone give me input?

    We billed 99205,25 (New Pt E & M)
    96118 (Neuropsychological testing)

    According to CCI edits: column 1 99205 pairs with 96118 but allows a modifier

    We appended the modifier 25 on the E&M as a separate service from the "procedure".
    The carrier states this is incorrect and it should be billed as 99205, 96118,59 (using modifier 59 on the procedure).

    However, according to CCI edits, modifier 59 should not be used unless there are 2 procedures. CPT guidelines would dictate using modifier 25 in order to bill the E&M but the carrier states this is not consistent with the CCI edits. CCI edits aren't exclusive to modifer 59 are they?
    The carrier is correct - Column 2 bundles into column 1. You should add a 59 to 96118.

  3. Default
    Oh, I forgot to mention when we bill Medicare Part B, they process the claim as 99205, 25 and 96118.
    Why do you suppose Medicare separates the E&M out with Mod 25 to unbundle the two codes and the commercial carrier doesn't. Is there anything in writing? Thanks!

  4. #4
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    Quote Originally Posted by catrina.thomas View Post
    Oh, I forgot to mention when we bill Medicare Part B, they process the claim as 99205, 25 and 96118.
    Why do you suppose Medicare separates the E&M out with Mod 25 to unbundle the two codes and the commercial carrier doesn't. Is there anything in writing? Thanks!
    http://www.cms.gov/MLNProducts/downl...NCCI-Tools.pdf

    I'm not certain why Medicare would allow it to process that way. The commercial carrier's edit system is based off of the NCCI edits. The link provided explains how the tables are used; the modifiers that are allowed to override NCCI edits are -25 for Column 2 E/M services, and -59 for Column 2 procedures. It's not necessary to have 2 procedures paired together in order to apply a -59 modifier to one.
    Although conventional wisdom usually dictates that if something's bundling with an office visit, the office visit gets the modifier, this isn't always the case. The reason that 96118 bundles into the office visit (instead of vice-versa), is that Psychological and Neuropsychological testing incorporate many of the same functions as E/M services. In fact, the CPT guidelines go as far as to say that anything less than the specified descriptions of these services (referred to as a 'mini-mental status examinations'), are to be reported using Evaluation and Management codes. It's an unusual circumstance, where the burden of proving that one service went above and beyond the other is reversed, with the E/M becoming the basic service, and the procedure having to meet specific criteria to be considered separately identifiable.
    Normally, when you have a procedure and E/M on the same day, the procedure is one that requires some sort of pre-and post-service work (such as checking vitals, or monitoring the patient for a short time for signs of an adverse reaction). In order to be able to bill an E/M in addition to the procedure, you have to demonstrate that you met elements that went above and beyond that pre-and post-service procedure work (like gathering History information, performing a more detailed exam, and making a medical decision). However here, all of the E/M work could feasibly be considered a 'portion' of the procedure - the fact that an E/M was done isn't in dispute. Whether the provider went above and beyond that and met the criteria for 96118, is. That's the reason that it's set up as the column 2 code on the NCCI edit table, and why the commercial carrier is requiring you to append a modifier to it, and not to the E/M. Medicare's allowance of the codes may very well be a mistake; it certainly goes against their own edit tables. I would advise that you ask them directly about it, so that if you need to submit a corrected claim to avoid a future payment recovery, you can. As far as the commercial claim goes - they have all of the proof they need to back up their denial. Your best bet is to comply, because they're not in the wrong. Hope that helps!
    Last edited by btadlock1; 07-20-2011 at 12:37 PM. Reason: Spelling!

  5. Default
    After MORE research on the NCCI edits, I still hold the opinion that this was billed correctly. Under the NCCI tools on the CMS website, there is an article about the mis-use of modifier 59 which distinctly states that it is used for multiple "procedures" and since only one procedure was administered, the Modifer 25 indicating a separately identifiable E&M would be the appropriate code. It also states that modifier 59 is used when services not normally billed together are billed for one reason or another. Which also, would not fit this situation, as PPI tests are often billed with an E&M service. So confusing, isn't it???

  6. #6
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    Quote Originally Posted by catrina.thomas View Post
    After MORE research on the NCCI edits, I still hold the opinion that this was billed correctly. Under the NCCI tools on the CMS website, there is an article about the mis-use of modifier 59 which distinctly states that it is used for multiple "procedures" and since only one procedure was administered, the Modifer 25 indicating a separately identifiable E&M would be the appropriate code. It also states that modifier 59 is used when services not normally billed together are billed for one reason or another. Which also, would not fit this situation, as PPI tests are often billed with an E&M service. So confusing, isn't it???
    CMS's articles can be misleading. I recommend this one: http://oig.hhs.gov/oei/reports/oei-03-02-00771.pdf

    "Specifically, the CCI edits contain pairs of Healthcare Common Procedure Coding System codes (i.e., code pairs) that generally should not be billed together by a provider for a beneficiary on the same date of service. All code pairs are arranged in a column 1 and column 2 format. The column 2 code is generally not payable with the column 1 code. Throughout this report we will refer to the column 1 code as the primary code or service and the column 2 code as the secondary code or service.
    Under certain circumstances, a provider may bill for two services in a CCI code pair and include a modifier on the claim that would bypass the edit and allow both services to be paid. A modifier is a two-digit code that further describes the service performed. Thirty-five modifiers can be used to bypass the CCI edits. Modifier 59 is one of these modifiers.
    Modifier 59 is used to indicate that a provider performed a distinct procedure or service for a beneficiary on the same day as another procedure or service. It may represent a different session, different procedure or surgery, different anatomical site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries). Modifier 59 should be attached to the secondary, additional, or lesser service in the code pair. According to CMS, this is the second code in a CCI code pair. When modifier 59 is used, a provider's documentation must demonstrate that the service was distinct from other services performed that day."

    Note the use of the word 'services' as opposed to strictly 'procedures'.

  7. Default
    The Modifier 59 article states:
    Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only, if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes. The NCCI edits do not specifically state which modifiers can be used in which column -therefore, directing us to use CPT Modifier guidelines - in which case, the only modifier that will separate an E & M service from a procedure is 25.
    I sure appreciate everyones input - thanks all!

  8. #8
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    Quote Originally Posted by catrina.thomas View Post
    The Modifier 59 article states:
    Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only, if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes. The NCCI edits do not specifically state which modifiers can be used in which column -therefore, directing us to use CPT Modifier guidelines - in which case, the only modifier that will separate an E & M service from a procedure is 25.
    I sure appreciate everyones input - thanks all!
    I think that's where we're not on the same page - yes, a 25 modifier is the only code that can separate an E/M from a procedure, but that's not what's happening here. In the case of 96118 and 99205, you are actually separating the procedure from the E/M. It sounds like the same thing, but it's not. As I explained before, most of the time, it's necessary to prove that you went above and beyond the work of the procedure, to be reimbursed for an E/M. In this situation, you're having to prove that you went above and beyond the work of the E/M, to meet the definition of the procedure. All of the guidance that's making you believe that anytime an E/M is involved, the only appropriate modifier that can be used is -25, is correct when the E/M is the service that must be defined as distinct.

    But that advice is not applicable in this situation. We're not talking about adding a modifier to the E/M - it does not need one. The code that must be identified as 'distinct' is 96118. It's not appropriate to add a 25 modifier to 96118. Just as the definition of modifier 59 refers to to modifier 25 for E/M services, modifier 25's definition states, " For significant, separately idetifiable non-E/M services, see modifier 59."

    I really can't think of another way to explain it. All I can tell you is that this is not a battle you're going to win with the carrier. When the OIG's instructions explicitly say to add the modifier to the column 2 code to overcome an NCCI edit, the carriers have all of the support they need to require you to add a modifier to 96118 when it's billed with an E/M. Good luck to you...

  9. Default
    I appreciate your input - thank you.
    My objective is to understand - not necessarily win. I really don't see these as "battles", rather trying to interpret the "guidlelines" and apply them correctly. The problem we in practitioner offices have, is accommodating ALL the different carriers interpretations of the rules - where the carriers seem to think their interpretations are the final say and many times (as in this case) they contradict one another. Every other carrier we work with, processes the claim the way we billed it. In fact, most of the time, this particular carrier processes it the way we bill it. Certainly makes things difficult- but not impossible. Thanks again for your input - although not resolved, very helpful to see it from another perspective. This forum is great.

  10. #10
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    Quote Originally Posted by catrina.thomas View Post
    I appreciate your input - thank you.
    My objective is to understand - not necessarily win. I really don't see these as "battles", rather trying to interpret the "guidlelines" and apply them correctly. The problem we in practitioner offices have, is accommodating ALL the different carriers interpretations of the rules - where the carriers seem to think their interpretations are the final say and many times (as in this case) they contradict one another. Every other carrier we work with, processes the claim the way we billed it. In fact, most of the time, this particular carrier processes it the way we bill it. Certainly makes things difficult- but not impossible. Thanks again for your input - although not resolved, very helpful to see it from another perspective. This forum is great.
    I understand and respect that perspective. I work for a practice management company with over 120 providers, and I got my start (and the bulk of my experience) doing commercial follow-up. Trust me, I know how you feel - I'm just trying to save you some time. I've argued some of the exact same principles as you have, on this issue (although with 96110, instead of 96118), and I've taken it as high as I could within the payer's appeal system - and still lost. I'm not saying don't ever try - if you think you're right, and you can back it up with something, don't give up. But sometimes being right isn't enough to win.
    These guidelines aren't black and white - particularly with CPT - they're designed to have a lot of gray areas. Interpreting them isn't an exact science; it's more of a form of art. Being able to creatively interpret the rules makes dealing with commercial payers more challenging, but it also makes it more interesting. You can't win them all, but it sure is worth it when you get the ones you do. Keep your attitude - it'll serve you well.

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