(PDF 75 KB)
The Correct Coding Initiative (CCI) can have a tremendous impact on payment of surgical claims when more than one procedure is performed in the same operative session.
What is the CCI? Medicare policy dictates that certain pairs of services should never be billed separately when performed by the same provider on the same patient on the same day, and there are other pairs of services that can be billed separately only under certain circumstances. The CCI identifies those services by listing pairs of CPT or HCPCS codes that fall within those two categories. These lists are updated quarterly—on Jan. 1, April 1, July 1 and Oct. 1. Each pair of codes is referred to as a “CCI edit.” CCI edits do not apply to subsequent procedures performed on the same eye during the global period.
What are bundled codes? This is another way of referring to pairs of codes that shouldn’t be paid together.
There are three types:
- Mutually exclusive—these are pairs of codes that can never be paid separately. On the CCI list, these pairs of codes have an indicator of “0.”
- Comprehensive—these are pairs of codes that can be paid separately when the subsequent surgery is on another site, such as the other eye. These have an indicator of “1.”
- Errors—these are pairs of codes that were bundled in error and should be resubmitted for payment. These have an indicator of “9.”
Why worry about bundled codes? If you submit a pair of codes that are mutually exclusive, you will only be paid for the primary code. And if you submit a pair of codes that are comprehensive, you will only be paid for the code that has the lesser dollar amount.
7 Steps for Optimal Billing
So how do you make sure your coding is correct?
- List all the procedures performed.
- Arrange that list in order of the payer allowable.
- Check every combination of CCI edits, to find out which codes on the list are bundled. (Go to www.aao.org/aaoe and select “Coding & Reimbursement” for a link to the list.)
- When codes are bundled together, eliminate the one with the lower payable.
- Link the appropriate diagnosis codes.
- Append the appropriate modifier(s).
- Submit your claim.
Example of How (and How Not) to Bill
During the same operative session, a surgeon performed three procedures on the patient’s right eye: an amniotic membrane transplant (CPT code 65780), conjunctivoplasty with graft (68326), and an excision of a conjunctival lesion (68115).
List the three CPT codes involved in order of allowable amount (see chart), and then refer to the CCI to see if it lists any of the six possible pairs of codes—65780/68115, 65780/68326, 68326/65780, 68326/68115, 68115/ 65780 and 68115/68326.
The best way to code for this would be to submit 65780–RT ($800) and 68326–RT (50 percent of $600). Note: Many payers no longer require use of modifier –51 to indicate that multiple procedures were performed in the same operative session.
But what if you submitted all three codes? You would still be paid for code 65780 ($800), but the other two are bundled together, so you would be paid for the one with the lower allowable—68115 (50 percent of $168).
|Example: Demonstrating Steps 1, 2 and 3
||Not bundled with 68115 or 68326.
||Not bundled with 65780 or 68115.
||Bundled with 68326. Not bundled with 65780.