Why aren’t physicians paid for each CPT code performed the same day and during the same session? The answer lies in National Correct Coding Initiative edits (often abbreviated to NCCI or CCI).
In this two-part series, we will define CCI edits and how they impact the claim submission process so that you appropriately maximize reimbursement. We will also provide examples of when unbundling is appropriate and when it’s not.
CCI Edits: An Overview
At the beginning of each January, April, July and October, CMS publishes new CCI edits, which slightly change how you can code certain procedures. Sometimes these edits have big implications for ophthalmology; sometimes they only make a small difference.
CMS developed these quarterly CCI edits to promote national correct coding methodologies, control improper coding and avoid inappropriate payments. CCI edits usually bundle components you could previously code separately: tests with other tests; tests with surgeries; and surgeries with other surgeries, when performed on the same patient on the same day and during the same session. Medicare Administrative Contractors, Medicare Advantage and commercial payers all use these edits to review claims for irregularities during processing.
To aid in navigating the CMS website, the Academy coding section always has a direct link to the latest CCI files. You can also find the latest edits. This information is also found in the 2016 Retina Coding: Complete Reference Guide and the 2016 Coding Coach: The Complete Ophthalmic Reference. The electronic version of Coach provides the quarterly updates automatically.
How to Decode the Edits
CCI edits are listed in a Microsoft Excel table (see below) with two columns of codes. The CPT code in column 1 generally represents the major procedure or service performed. The CPT code in column 2 may represent a component of this code. Therefore, the code in column 2 may not be payable because its value is accounted for in the payment of the code in column 1.
The table also includes the effective date and an indicator: 0 indicates that the codes are mutually exclusive and can never be unbundled; 1 indicates an unbundling is allowed if certain criteria are met and 9 indicates an error in the edit.
When unbundling is appropriate, you must use a modifier. When unbundling is appropriate, append modifier -59 Distinct procedural service to the CPT code in column 2. However, because the use of modifier -59 is so frequent, CMS published four additional modifiers last year to provide greater clarity as to why the unbundling is indeed appropriate. (Part 2 of this series will address these modifiers in more detail.)
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The table lists several different bundles impacting ophthalmic services. Below are examples defining each indicator and how to appropriately submit the CPT code(s).
In the table above, CPT codes 92133 SCODI; optic nerve and 92134 SCODI; retina have an indicator of 0, meaning that both tests can never be paid on the same day. Choose the test that provides the most information needed today as the code you submit for reimbursement.
CPT codes 92020 Gonioscopy and 92018 Exam under anesthesia also have CCI edits of 0; they, too, are never payable on the same day.
Indicator 1 represents circumstances in which the edit can be unbundled. Some reasons for unbundling may be different session or different site. CPT code 92225 Extended ophthalmoscopy is bundled with CPT code 67228 PRP and can be unbundled depending on the circumstance. Because extended ophthalmoscopy is a unilateral procedure, apply modifier -59 to the test when the laser is performed in one eye and you draw and label pathology from the other. This indicates it should be unbundled.
Your claim submission for this example might look like this:
92225 -59 -LT
The only time it is appropriate to unbundle CPT code 68200 Subconjunctival injection from CPT code 65785 Insertion of intrastromal corneal ring segments is when you perform these procedures on separate eyes. Otherwise, only submit CPT code 65785 for payment.
65785 (facility, $394)
68200 (facility, $36)
If you submit both codes for payment, the lesser amount will be paid, resulting in a loss of $358.
CPT code 92014 Comprehensive, established patient eye visit is bundled with CPT code 66821 YAG capsulotomy. The edit was deleted during the same period of time that it was created, as they realized their error in bundling the exam with this procedure.
Having a clear understanding of what the CCI edits are and how they impact services you provide is key to timely payment of claims. Next month, we will provide additional scenarios that ophthalmologists face every day and discuss modifier -59 and how it impacts services that are unbundled.
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About the author: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding Bulletin, Ophthalmic Coding Coach and Ophthalmic Coding series.