By Joy Woodke, COE, OCS, OCSR, Academy Director of Coding and Reimbursement
What happens if you don’t bill appropriately for bundled codes? You will experience denied claims and underpayment for services, and you even may place your practice in an auditor’s crosshairs. Fortunately, you can avoid these problems by recognizing some key bundling principles and following your payers’ published policies.
What are bundled codes (aka CCI edits)? Bundled codes are pairs of codes representing services that can’t both be billed when performed by the same physician on the same patient on the same day. These pairs are often referred to as CCI edits or, sometimes, NCCI edits. These are acronyms for the National Correct Coding Initiative, which publishes lists of those pairs.
Take action. Make sure you and your staff understand how to bill for bundled codes, and stay current with your payer’s policies and the latest lists of CCI edits. Test your coding competency by tackling the questions below, which touch on some core principles of CCI edits.
When to Check for Updates
Q. How often are CCI edits updated, and where can you find these bundles?
A. CMS publishes updates to the CCI edits quarterly. If there are significant changes that impact ophthalmology, they will be posted at aao.org/coding, where you also can find a link to the CMS website. The CCI updates go into effect on Jan. 1, April 1, July 1, and Oct. 1.
Action steps. Schedule reminders to check on the CCI updates. Each quarter, you’ll want to determine whether any updates involve codes that you use.
You also can create a reference listing services that your practice performs frequently. It should flag code pairs that are bundled together.
When Can You Unbundle?
Q. When you review the table of CMS CCI edits and identify a pair of codes that are bundled, you will see a separate column titled “Modifier,” which has a “0,” “1,” or “9.” What does this mean?
A. These numbers indicate whether you can bypass the edit and whether the code pair is still a valid edit.
0 indicates that you cannot unbundle the edit. This is a “mutually exclusive edit,” and there are no circumstances in which both procedures of the code pair could be paid when the same provider performs them on the same patient on the same day.
1 indicates that there are circumstances in which the edit can be unbundled. Both the procedures of the code pair can be paid separately if you have met the definition of modifier –59, which is used to flag that a service is a distinct procedural service.
9 indicates that a former edit has been deleted. In other words, although the two codes were formerly bundled together, that is no longer the case. For example, the initial code pair may have been bundled by mistake.
Action steps. Identify mutually exclusive services that your practice provides. Next, flag these in your practice management system so that they are not inappropriately billed for the same day of service. For example, you wouldn’t want to bill CPT code 92133 (OCT of the optic nerve) for the same time as 92134 (OCT of the retina).
OCT and Fundus Photo
Q. When performed on the same day, CPT codes 92134 (OCT of the retina) and 92250 (fundus photo) are bundled with an indicator of 1. When is it appropriate to unbundle with modifier –59?
A. See if the payer has a published policy that provides specific scenarios for unbundling the codes and that offers guidance on what you need to document in the patient’s chart. If the payer doesn’t have such a policy, only bill for the test that contributes most to the medical decision making for the encounter.
Action steps. Research payer policies for testing services to identify which codes are bundled and which of those can be unbundled. To find Medicare Part B policies of your payers, visit aao.org/lcds.
Same-Day Surgery Codes
Q. When is it appropriate to unbundle surgery CPT codes performed during the same surgery session by the same surgeon?
A. The most common scenarios are when the two bundled codes are performed in separate structures (e.g., opposite eyes) or separate incisions. For example, a cataract surgery (CPT code 66984) in the right eye is performed the same day as an Nd:YAG laser in the left eye (CPT code 66821). These two codes are bundled with an indicator of 1. Because they are performed in separate structures, it would be appropriate to unbundle them with modifier –59.
Action steps. Create a surgery checklist that ensures a review of all CPT codes performed during the same surgical session and identify any CCI edits. For the most common procedures in your practice, create a quick reference guide that includes the CCI bundles and the appropriate indicator.
Use These CCI Resources
To complement your internal resources, visit aao.org/coding for links to the quarterly CMS CCI edits. To quickly access CCI edits, you also can purchase the Academy Coding Coach or Retina Coding: Complete Reference Guide at aao.org/codingproducts.
If you are a member of the American Academy of Ophthalmic Executives (AAOE), you also can get CMS alerts about CCI edits and other issues via AAOE-Talk (aao.org/practice-management/aaoe-talk-overview) or via the weekly Practice Management Express e-newsletter. If you are not an AAOE member, visit aao.org/membership/join-aaoe.