CCI, NCCI, PTP, MUE and Add-on Code Edits Explained

Video Transcript

Good afternoon everyone. Welcome to this week’s episode of Did You Know. This week on Did You Know we’re gonna talk about CCI and NCCI edits. We’re going to cover quite a bit of information as we look at this.

What You’ll Learn

We’re going to talk about what CCI and NCCI are. We’re going to talk about where you can find information on the NCCI edits and covering number of areas of information around NCCI edits. How often they’re updated. What the different types are. There’s PTP, MUE and Add-on. All of these different varieties. Then we’re going to talk about when does NCCI applies, who’s supposed to use it and where you can find these specific edits.

Let’s go ahead and dive right in and get started.


We’re going to start out by answering that first question. What is CCI or NCCI? NCCI stands for the National Correct Coding Initiative and sometimes we refer to it just as CCI or the Correct Coding Initiative. This is where CMS has developed certain edits. There are certain services certain CPT codes that are bundled into other CPT codes. Usually when we think about bundling. When we think about when one code is included in another, we start thinking things like the guidelines in our CPT manual. Absolutely those bundled things for us. But in addition to that, CMS has additional edits that they’ve built that may or may not be referenced in CPT.

In building these things and identifying which code should be bundled together as part of one unique service, they’ve looked at things like the coding conventions that are in CPT but they’ve also looked at both their national and their local coverage policies and any edits that the local carriers may have established. When I talked about local carriers, talking predominantly about your medicare administrative contractors, your MACs. These coding guidelines also include anything that has been developed by national societies. Things like the American Psychiatric Association or the American Association of Orthopedic Surgeons. They put out their own guidelines and policies as to what they feel is included in a service. Oftentimes those are the things that CMS that has looked at in determining, ‘okay, is this part of this one CPT code or can they build it separately?’.

They’ve also conducted an analysis of standard medical and surgical practices. They looked to see, ‘what is consistently done?’. If it’s something that has to be performed, for example, if you’re going to perform an endoscopy on a patient maybe they’re going to do an esophageal endoscopy. Oftentimes there’s got to be an intubation that’s done. Some sort of intubation. That maybe be bundled as we start to look at the services. Those were the types of things we’re looking at. Obviously they review current coding practices to see, ‘should this be a separately allowable service?’. Now, when we look at CCI and NCCI, I’m giving you a little nasty hyperlink on the top of the slide. That’s gonna take you directly to the CMS website. I’m actually gonna go ahead and go over to that link right there at the top, myself. If you don’t have this link available to you. Maybe you’re thinking about this in a few weeks and you’re like, ‘Oh I know Chandra told me about that on that Did You Know episode. Well, I don’t want to go back and look it up. I don’t have that kind of time. How can I find it quickly?’. Go to google and type in NCCI edits. It’s going to pop up the same link as it is in the first choices. Let’s go ahead and go over to that CMS link.

When you click on that link, this is where it’s going to take you. Notice I’m on the website. I’m under medicare and there’s actually a page to hold into nothing but the national correct coding initiative and those related edits. If you were to read through this page, you will find out right here in this first paragraph is where I gathered much of the information we have on that slide. Where we talked about CMS developed these edits. The reason they developed these edits is right here.

They want to promote correct coding methodologies and control improper coding that leads to inappropriate payments. This all started particularly for part B claims. It makes sense because that’s where we use CPT. As we look through here, you’ll see this actually began clear back January 1, 1996. That’s when we started with some of the national correct coding initiatives being implemented for medicare, being affected for CMS and medicare. They’ve gone on to add other code sets like the MUE edits. Things like that. We’re going to talk about what all of these acronyms mean.

But the important piece that I want to point out here is that this was expanded and covers not just part B or part B services when we talk and we think about physicians. I know that’s what a lot of you on the professional side were thinking right now, right? I use NCCI edits “because according to my physicians” but it actually also affects the outpatient code editor or the OCE for those outpatient facilities including your therapy provider, your skilled nursing facilities, your comprehensive outpatient rehabilitation facilities, your home health agencies. All of those are included in this. You could use these edits in a number of different places. They have since expanded the tables that we’re gonna look at. There are separate tables for professional services then there are for facility services. They really expanded this code set.

What is in NCCI all about? Well NCCI is as I said they’re making sure that certain services aren’t bundled. The way they do that -if you come down a little bit further on the page here- you’ll see they talked right here about procedure-to-procedure edits. Those procedure-to-procedure edits are what we’re talking about when we say CMS is determining whether or not one service is bundled into another service. They’re telling you how one procedure relates to another. That’s why they call them PTP or procedure-to-procedure edits.

This is set-up in the table format so you can check one coding against one other code in any particular time. It has two columns of codes just as we’d expect, your column one and your column two because I’m checking against each other. When you look at this, there’s a manual that goes along with these edits. Many people know about NCCI edits especially if you’re working on the billing side of things. People will oftentimes say, ‘Well I got a denial for this service when I reported them together. The denial said, one service was included in the other service’. But I don’t think it should be. We will usually tell you if you talked anybody else that experience will say, ‘did you go check the NCCI edits?’. Is there a check tool that alerts you that those can’t be reported together? Most people are familiar with using the editing system but what they failed to realize is there is an entire policy manual that goes along with those edits. We’re going to look at that policy manual as well because that will answer a lot of your questions if you’re just getting into the billing and coding side of things.

The NCCI edits remember this come in to play from a billing perspective. This will not be something that you’re tested for the CPC exam if you’re testing for AAPC. That CPC exam tests you strictly on the coding requirements. It will test you on whether or not the guidelines is in the CPT manual. If they’re going to step further and set it up as an NCCI edit, maybe they say CPT says, ‘you can build them separately’ but CMS has come out and said, ‘no no no that service is included in this other service’. Those are going to be things that will test you on, things like the CPB or the certified professional billing certification. We’ll talk through those.

I’m going back to my slide for just a minute. So we’ve identified what NCCI is, right? It’s the national correct coding initiative. It’s there to help control improper coding that leads to improper payments.

PTP Edits

In addition to that, we need to answer a couple of other questions. We’ve identified that there are edits and that there are different types of edits. The first question that I normally get is ‘You’re gonna explain this to me. You’ve already told me NCCI edits that there are two codes being checked against each other and that they’re already about controlling and proper payment. Correct. You should also know they update this on a quarterly basis. If you’re maintaining your own spreadsheet system, you want to make sure that you’re going out and downloading in a quarterly basis because they post new files every quarter.

There are three predominant types of NCCI edits. By at large, the biggest one are those PTP edits. Those procedure to procedure edits. The ones where I said we are looking at the CPT code and seeing if it is included in this other CPT code. Now, when I say CPT code, that’s probably a bit of misnumbered. It could be CPT code or HCPCS codes because remember CPT codes are one type of HCPCS code or those HCPCS codes so it could be either one of them. We’re going to look at that procedure to procedure codes. When we go and look at those, we are going back to the same page I was on. But if I go to the top of this page over here on the left-hand side that says PTP coding edits. I can find out more information just about the procedure-to-procedure that are set up. This is where they explain. These procedures are either assigned to a column one or a column two file or the mutually exclusive list based on the criteria for each of the edits. Mutually exclusive identifies the procedures that could not be performed at the same patient encounter because those two procedures were mutually exclusive based on either anatomic, temporal or gender considerations.

What I’m telling you there is if you have mutually exclusive edit that means that you could not possibly, physically have done both procedures at the same time. You either did one or you did the other. They’re mutually exclusive. They can never be performed together. In addition to those mutually exclusive edits, there are a number of other types of edit. They probably going like edits edits edits. What are all of these edit things look like? What I’m going to encourage you to do is if you scroll -. I’m on the PTP coding edits page ‘cause I went to that link for NCCI and then I click over on the left-hand side of the PTP coding edits. If we scroll down to the bottom, this is where you’re going to find the actual tables full of edits. You’ll notice that the two for practitioners are purple on my screen. Those are the ones I’m gonna show you examples of the hospitals. Once we’re there, if you worked on the hospital facility side of things your skilled nursing facilities, your home agencies, your outpatient physical therapy offices. Things like that.  Those are where are those facilities are gonna come into play. But I’ll deal with the practitioner ones because those are the ones that I’m most familiar with and those are the ones the I find used most frequently.

When you download these two files, there are two of them. Make sure you get both of them. You’ll notice this first one goes through 39599 and the next one then starts with 40490. They’re just so large to put them both on the same thing. Download them separately and they’re gonna come up in an excel file. Let me show you what they’re gonna look like. They’re gonna pull up in a file that looks about like this. What I did is I just merged both of them together.

This is file one. You’ll notice it’s in F1 at the end of the file name. I just put file 2 as a separate tab in the same workbook so I could click between the two. This was set up so that there are different columns, column 1 and column 2. Column D over here gives you the effect of date. How long does the edit has been around? How is that edit been deleted? There is a deletion date if they’ve deleted that edit because sometimes they change the code descriptor. It may not longer be a bundled service. No longer be a part of that. So over here, you’ll have the deletion date. If there is a star, that means it is still active. There’s no deletion date. It’s still a valid edit. Then you come to the tricky row edit as I call it, the column F. Column F is where you’re going to have a number. You either get a 0, 1, or 9. 0 says you can not put a modifier on these two codes. Basically a zero tells you, these things can not be reported together. Typically, because the CPT manual instruction saying you can not report this two services at the same time. You can’t do it. If you have a one, it says that a modifier is allowed.

However, you better review the documentation. You better look at the NCCI policy manual to make sure that they are truly separate services. As you look down here, you’ll see sometimes that these are mutually exclusive procedures. Typically you did one or the other. Or it may be that it’s a standard medical and surgical practice customary that you usually perform both services together. If that is the case, these edits gave you an idea as to which one is going to be paid. I’ll show you what I mean just in a minute. You may also have a 9. Let me give you an example of one that has a nine. Let me do it the easy way. I’m gonna do a search which is the control F and find the 9. Let me expand my search. Let’s do an edit. Find. I’m going to find entire cells only that have a 9 in them.

Here’s the example, this says there are two services here. The edit has since been deleted unfortunately but it says that there’s no modifier needed. If you see a 9 and this is applicable. What that’s telling you that you don’t need a modifier. The two things are not going to be bundled together. It’s not a mutually exclusive edit. It’s not one where standard surgical practice is. Typically, they’re separately reportable. Go ahead and report them. You can get paid legitimately for both services. This is kind of a rationale behind all of these different edits. There is, like I said, a couple of different pages of edits. We’re gonna come back and have another go with these edits in just a few minutes. But I wanted you to have an idea of what the table looks like.

Now, when we’re looking at the table-. Initially, I told you if it has one and the one says that you can’t have a modifier or allow a modifier, you better go out and look and make sure what the policy manual really says. You probably ask, ‘where do I find the policy manual?’. Well, I’m going to show you. Back on the same page. We’re still on my PTP coding edits but I’m going to go back to just the NCCI page. All I do is click this link right here before it says ‘National Correct Coding Edits’. I’m going to scroll to the bottom. Down here, they give you lots of really useful tools. This first one says, ‘how do you use the NCCI edit tool?’ Well, I’m kind of showing you how to do that but I already have that popped open in the tab.

There is a pdf file by the medicare coding network from CMS that shows you just how to use this. How do I look it up? What are those different indicators mean? Like the 0, 1, and 9. How do I properly submit my claims? As you scroll through this document you’re gonna find that the answer to many of the questions that you have. They go through all of the same sorts of things that I’m going through. They also give you a lot of background on the NCCI edits. Where they came from? What is their use? All of that. Beyond just the fact that they’re there to help ensure proper payment for services rendered. They answer all of these different questions for you. In addition to that how-to manual, if you go down towards the bottom, they include chapter 23. It says ‘Fee Schedule Administration and Coding Requirements’. That is chapter 23 of the claims’ processing manual which is one of our internet-only manuals. If you were to open that which I’ve already clicked on it and had it opened in another tab, this goes through how to report your rules.

This is your general rules for claims submission. It does split into general rules for diagnosis coding. What are you doing with an outpatient claim vs inpatient claim? What about those ICD procedure codes which are now ICD-10-PCS codes. It used to be ICD-9 volume 3, right? They go through all of the different areas for you and explains some of the same things. In addition to that, they give you a really nice article on the usage of Modifier 59. Now when we talk about NCCI edits, the reason that I wanted to bring this up is that oftentimes, people will receive a denial and they will say something about, ‘will this procedure be bundled in this procedure?’. They will go look at the NCCI edits and see that a modifier is allowed. Without even looking at the documentation, they’ll slap a 59 on there. The reason I put a 59 on there is they know it’s going to unbundle the service. If I said, ‘Here’s procedure A. It includes procedure B. You put a 59 on there, what’s going to happen?’. Well, you just told me that A and B is totally separate. They’re distinct procedural services.

Well, you need to make sure that you are looking at the documentation before you go that far. Because we want to make sure that they truly are distinct procedural services. But in addition to those documents, they give you the NCCI policy manual for medicare services. This is the manual that goes along with those edits and tells you what to do. Now you’ll notice, this is a zip file. All the other ones you have a pdf document on the end of them. This one is a zip file. I’m going to take you on a different screen. My screen is going to be a lot smaller. It the one that won’t let me in large but it’ll give you an idea on what it looks when you download that file. Let’s go a look over and take a look at what it looks like. Down here at the bottom, these are all of the files that are included in that zip file. Up here at the top, it just gives me a preview of what it looks like. These are all pdf files.

I’m going to open a few and give you an idea of what it looks like. The first thing that I’m going to open is the table of contents. Let’s open the table of contents. See what the pdf file looks like. Let’s see if I can fix this up here. Here we go. We can make it really nice and big for you. As we scroll through here, the table of contents you’re going to see. It tells you right up here at the beginning. They’ll give you an introduction, the purpose, the background behind it, sources of information, a list of acronyms. That’s huge, right? We’re always trying to figure out what medicare is calling all of these abbreviations like NCCI, MUE, CMS, E/M. We’ve got all of these acronyms that you’re going to be familiar with. They also go on to further define the surgical package. It’s so very important that you’ll understand that because I know in CPT book there’s a definition of the surgical package from a CPT perspective. It tells you things like in evaluation and management service the day of or the day before the service is performed if it’s subsequent to the decision for surgery. It tells you things like post-op information. All of the writing orders in documenting the services. This definition actually goes much further than that.

Let’s actually go down to page i12. We’ll do a little search here. We’re going to go down here to-. Actually I have to go to that section. Sorry about that I wasn’t thinking. So I want to go to this page. This is in chapter one of the correct coding policies. I’m going to close this pdf file. I’m going to go back to my menu bar. You’ll see I have chapter 1, which is where it told me that one was chapter 2. Chapter 2 down to chapter 13 give you the code ranges associated. This would be anything that starts with the 0 so your anesthesia services. Anything that starts with the 1 your integumentary system. Anything that starts with the 2 the musculoskeletal. So forth and so on. All the way through here. Down at the very bottom, you’ll get into those HCPCS codes and even those category 2 codes. Let’s take a look at the general coding guideline cause it told me I wanted to look at those definitions of the surgical package. Let me blow this up for you again.

I’m in chapter one and I want to go down and look for…I want my continuous scroll to keep going. That’s what I want. Here we go. We’re going to go down and look at that definition of surgical package which tells me around right here is on page i12. I’m going to look for i12. We’re going to go right down here. I12 there we go. If we come right back at here, this page is i12. It says here the medical and surgical package. This goes on and says, ‘Hey guess what, most medical and surgical procedure include pre-procedure, intra-procedure and post-procedural work which we already knew. But it comes on down here to tell you that many invasive procedure require vascular airway access. That’s going to be bundled. For example, airway access is here for any types of general anesthesia. It’s not separately reportable. There’s no CPT code for elective endotracheal intubation.

CPT code 31500 describes an emergency endotracheal intubation and should not be reported for elective endotracheal intubation. When they use the word elective, that doesn’t mean that you went in and said, ‘Hey I want to be intubated’. It means that you are in a non-emergency procedure. You had some sort of scheduled procedure. We have to intubated you in order to do that procedure. That’s all they’re talking about with the word elective. That went and throw you off to think that it’s a cosmetic procedure or anything strange like that. These are your usual services that your providers are performing. They’re just not emergency services. The emergency situation would be something like, a patient came in with trauma and their airway collapsed or a patient who came in with appendectomy. We have to get them out right this very minute. It’s an emergency procedure. Those are the situations where we have to do an emergency endotracheal intubation. But this elective endotracheal intubation means maybe they came in and we’re doing bariatric surgery and put them out in order for them to be anesthetized in general anesthetic. We need to do an intubation to keep their airway going because if you don’t know under general anesthesia you lose control of your airway so you need somebody else to maintain that for you. They tell you right here, ‘We’re going to bundle airway access if it’s needed for general anesthesia. We’re going to bundle intravenous access if it’s done with surgical procedures, anesthesia procedures, radiology procedures that will require invasive contrast, nuclear medicine procedures.

All of these types of things. There’s a whole lot more bundled here than what we consider bundled in CPT. You’ve got to be familiar with these. That’s why I said, if you hadn’t had a chance to look at this policy manual or nobody’s ever told you about it, this will answer a ton of your questions as they relate to any edits that you may be receiving from your billing system. When I say that most billing systems, when you enter your CPT codes, they do what we call a front in claim scrubbing. They have these edits built in a table somewhere in that billing system. It runs through there before it claim on to the clearinghouse or the carrier. If it stays a problem, it says, ‘Oh there’s an NCCI edit.’, it’s going to kick it back out to whoever the person is that works the edits. Oftentimes it’s somebody who is doing the billing and the charge entry and the denial management for that particular provider. They have to work for those edits before it gets submitted to the insurance carrier. Once it gets submitted to the insurance carrier, if there’s still a problem, you could get a denial back from the insurance carrier that may still be related to these NCCI edits. So you’d want to come out in here and always check this policy manual first. Don’t worry we’re going through an example here in  few minutes where it shows you-. Somebody asked a question the other day about, ‘Why is my doctor putting 59 on these two procedures when CPT doesn’t say that they’re CPT bundled?’. We’ll go through that example here in a few minutes. I’m going to go ahead and close this out of here then I go back to my slideshow just a minute so I make sure I stand track. We talked a little bit about this procedure-to-procedure edits. We said that’s where medicare’s identifying one procedure is bundled inside another procedure.

MUE Edits

What are these MUE things? These are Medically Unlikely Edits. These were implemented in January 1, 2007. We did data service. On or after January 1, 2007, we started using MUE edits. Well, let’s go take a look and see what MUE edits are all about. I’m back on the same page for CMS right here in NCCI. But over here on the left, I’m going to click on the medically unlikely edits. This is where a claim may be denied or data service may be denied based on the fact that it is medically unlikely for whatever is being reported to actually occur. I like to use a kind of ridiculous examples that I’ve actually seen in the billing system. A good example of that is billing three units of a cholecystectomy. Cholecystectomy is the removal of the gallbladder. If your billing you remove three gallbladders from the same patient, that is highly unlikely. It’s highly unlikely that they have three gallbladders. So, those are the types of things that are considered medically unlikely edits and they’re going to kick out. They do update this on a quarterly basis just like they do to the PTP edits. You would want to make sure that you’re familiar with this as well. There’s a whole page all about medically unlikely edits. There’s a bunch of information on them. On the NCCI edit FAQs which we’ll look at here in a few minutes. And again, our practitioner table just for medically unlikely edits. You’ll see that there are two for this year because we have whatever came out January 1st and then updated again April 1st. You’d want to make sure that you’re looking at the current ones so you got all the information that you need for this quarter. So those are your medically unlikely edits.

Add On Code Edits

The next type of edit that we have is what we call on add-on code edits. You’re probably going, ‘Why do we even have edits for add on codes?’. If you know what an add on code is, an add on code are those in the CPT manual that have the plus symbol in front of them. It means they can’t be billed by themselves. They have to be billed in addition to another procedure. CMS actually explains  a few things. They put on these add on codes in place. April 1, 2013. The haven’t been around as long as the other edit when we think about NCCI and PTP edits being around since 1996. This is considerably longer period. When we look at this add on code edits they say an add on code is a HCPCS or CPT code that describe service that is always performed in conjunction with another primary service. There are things that they call an add on code with one exception. That says that those add on code with one exception means that it is a code that is eligible for payment only if it’s reported with an appropriate procedure performed by the same practitioner. If it is an add on code with one exception it’s never eligible for payment if it’s the only one  reported by the practitioner. Well those are the things that we would expect to see. We can’t report add on codes by themselves. They have to be built in addition with something else. In order to ensure that they’re actually checking for this, medicare created add on code edits to ensure that add on codes are only appropriately paid when they were billed with their primary procedure. If you go out to the NCCI initiative link that I gave you, we’re going to click on add on code over the left end of the menu bar. It will go through here and give you an idea of the different types of add on codes. They say right  down here that add on codes are identified one of three ways. The code is either listed in the CR or the subsequent ones as Type I, Type II or Type III add on code. Or, you can find them in the Physician Fee Schedule Database which we talked about in the previous episode of Did You Know here at CCO. Generally, the add no code has a global surgical period of ZZZ. That ZZZ said it takes on a global period of primary code that is build in addition to. Or in the CPT manual those add on code have that plus symbol which means you have to bill it with something else. You can find it one or three ways. Then they come down here and they distinguish them for payment. They say Type I. Type I add on code is a limited number of identifiable primary procedure codes. It only has certain things that it can build with. Those are the only primary procedure codes that can be associated with in order to get paid. A Type II says, it doesn’t really have a specific list of primary procedure codes. Those add on codes list the Type II add on codes but it doesn’t list any primary procedure code for them because you can kind of bill it with lots of different things. But they want you to make sure they encourage their contractors to their medicare administrative contractors, they know their fiscal intermediaries, to develop their own list of procedure codes that they expect them to be reported with. Type III add on code have some but not all specific primary procedure codes identified in the CPT manual. This would be things that Type III add on codes with the primary procedure codes that are specifically identifiable. These are things that there is not an exclusive list of primary procedures that they could be reported with. They could  be reported with almost anything as far as primary is go. These are very limited code set. This again is where the contractors typically put together a list. Now, for both the Type II and Type III, what I’m talking about the contractors putting together a list, I’m talking about your LCDs. Your local coverage determination. That’s usually where you’re going to find information on these local edits that are established by the Medicare Administrative Contractors. You’d want to make sure that you’re familiar with those on how their processing your different add on codes to ensure proper payment for your physicians.

Code-Pair Checking

Alright, so we have talked through what NCCI edits is and why we have it. We’ve talked through the PTP edits, the MUE edits, the add on code edits. So now, you’re probably ready to ask a few more questions. Before we go too far into. How do we actually use this code-pair checking? Do I have to pay for code-pair checking software? Does it only apply to medicare claims? All of that. Let’s back up for just a second and remember a few things. CMS developed NCCI. It’s all about medicare. That’s who it was developed for. Does that mean that it is exclusive to medicare? No. As they say on that Primary National and Correct Coding Initiative page on the CMS website, carriers began implementing the procedure-to-procedure, the PTP edits, January 1, 1996 or after. They started with the MUE edits, January 1, 2007. They started with the add on code edits, January 1, 2013. They say carrier. When they say carrier, they’re talking about their medicare administrative contractors. But by at large, medicare is not the only one that uses the NCCI edits. Most all commercial carriers have some form of NCCI edit that they also follow. They typically follow the national ones. They may or may not follow the local edits developed by the different regional Medicare Administrative Regional Contractors. They may also have their own code local edits that they include for certain services like those add on services. No. You should not be checking on the NCCI for medicare. You should be checking NCCI for all of your carriers because more often than not most of the carriers follow the National Correct Coding Initiative edits. That’s why they’re called national. Not just for National Medicare but many of the commercial carriers have followed suit as well when they talk about bundling.

Let’s get in to this last three question that we have on our agenda here. What is code-pair checking? Well, code pair checking is what most of us call going and looking to see if two codes can be billed together. It’s just kind of a slang that we use. Did you use a code pair checker? Did you see if those two services could be reported together. There is specific code pair checking software. Now I know I showed you that CMS spreadsheet of all of the edits, they’re all there. You could use that spreadsheet. It’s just most people do not find that easy to follow. They would rather have a code pair checker that tells them a little more explicitly what to do with the service. Do you have to pay for code-pair checking software. You don’t have to pay for it because you can use the excel spreadsheet. But if you want a code-pair checking software, yes, you will probably have to pay for it. It is usually included in many of your N coding services. I know things like find a code included. The AAPC coder, the software that they offer. Your three M encoder. Most of those types of packages include a code type checker. So we’ll take a look at a code pair checker and show you the difference between that in the excel spreadsheet. Does code-pair checking only apply to medicare? We’ve talked about this. No. Many other commercial carriers tend to follow those same NCCI edits. You want to make sure that you’re checking that and looking at their policy manuals as well. Let’s talk about a couple of examples here. Let me show you how a code pair checking software looks like.

I received a message the other day from a student who asked me, ‘I work in a clinic and I’m just starting to learn the billing side of things. I have a position who was billing two codes together’. He’s reporting a 59 modifier on one of the two codes and I can’t figure out why because there is nothing in the CPT manual that tells me he needs a modifier. The two procedures that they are reporting together are 64450 and 77002. Well 64450 is a type of nerve block, in case you’re curious, it’s a peripheral nerve block. I will have to tell you exactly where that nerve block is being performed. 77002, I believe is the guidance. The imaging guidance used in doing the nerve block. As a matter of fact, if we were to look this up in CPT, I’m going to pull out my CPT manual in a real quick so I could give you a little bit more definitive description here. If I am to look up 64450 in my CPT manual, what I find is 64450 says, I have an injection of an anesthetic agent and I am inserting it to other peripheral nerve or branch. There is nothing underneath there to tell me that I can not report it with some other service. There is no instruction in the beginning that says that I can not report it with imaging. I’m going to go look up that imaging code to make sure that there is no guidelines back there that says I can’t build the two together. 77002, if you look at the 77002, it says fluoroscopic guidelines for needle placement for example, biopsy, aspiration injection or localization device. See appropriate surgical code for the procedure and the anatomical location. It is included in all arthrographic radiological supervision and interpretation codes. Don’t report it with certain services. However, my 64450 is not in that list of things that it can’t be reported with. In my mind, I’m going alright, according to CPT they’re separately reportable. The provider is using a 59 modifier. I’m going to go look at CPT. Maybe there’s an NCCI edit and that’s why he’s using that 59 modifier.

Let’s start by using the table. Let me show you how this works. I’m in the table. I’m down there in my edits table. I’m going to do a control find and I’m going to look for my 64450. I want my 64450. I’m going to look through here it’s listed a bunch of times. I’m looking for it in my one column and my 77002 in the other column. This is why most people do not like looking through here. I’m actually going to do a search and see if it is in my column one. I’m going to do a find. I’m going to go specific, I’m going to say search by column instead of row and I want to find my 64450. It does not find it until that next column so I’m going to say look for my 77002 but I want to find it here. Find. Now the problem is if I remember correctly, this page. One of the things that I oftentimes fail to point out is  the reason that a number of people do not use these excel files and up for a code pair checking tool is these excel files are hundreds or thousands of line items long which means that sometimes your computers just don’t like to mess with them. I am running a really new mac and it will not cooperate with me. He’s locking up when I’m trying to find the code that I’m looking for because they’re so far in the sheet.

The other thing that you have to remember is there’s two sheets. This first sheet only goes to the 40,000 series of codes when we talked about what’s in column one. When I get to sheet 2 and I do that same search, that’s when my computer seems to be locking up. It doesn’t want to do the search for me and I give you the idea of what it does. It just gets stucked. It splits the screen and won’t ever finish processing. I’m going to go ahead and escape out of that and show you what would happen-. What I was looking for is the 64450 in one column with the 77002 in the next column to see what the modifier is for it. I will tell you that it does have an effective edit. It has not been deleted and the modifier that displays for those two combinations together is a one, saying that it is allowed. The reason I want to use the code pair checker is sometimes it’s hard from this spreadsheet to tell whether or not they can report them separately. Let me show you what a code pair checking tool looks like. Let me go over to here. I’m going to use Find-A-Code. That’s what we tend to use here at CCO.

So, I clicked on the NCCI edits validator. Right down here. My third box. I’m going to click on that. This tells me right upfront, this is the non- facility version. If I want the facility version, I actually have to change which one I have selected. I’m going to come over here and I said,my two codes were 64450. I’m going to hit return because I just want to see them separately.  And the 77002. You click this validate button. That’s what’s going to check the two together. This is okay. It’s calculating and it says, you have a warning. The 64450 is fine to report. It’s okay. You’re great. Everything is going to go fine. However, that 77002 when you add it to this there’s a warning. There’s an edit between 64450 and 77002. 77002 is the column two code meaning in that spreadsheet 64450 shows up in the first column. 77002 shows up in the second column. Those second column codes are the ones that are usually going to be bundled into the primary code. It says 77002 is the column two code. If you report both of them together, only the 64450 will be paid. However, a modifier can be used when appropriate. We need to make sure that it is appropriate to report both of them. The question I got when I say there’s an edit and it says we might be able to use a modifier if the two are truly separately allowable. The person says, ‘How do I figure that out?’. Great question.

This is where the NCCI policy manual comes into play. If we go back over to the policy manual, there’s still so much into this. Did you have any idea that there was going to be this much? I’m going to go into the CPT code in the 60000 series because I’m looking to that 64450 first. Let me continue a scroll. I’ll make it big for you. I want to find 64450. There are no specific codes for 64450 but it takes me to the code range. The 64450 would be included in. It says, ‘CPT codes 64400 – 64530 describe the injection of anesthetic agent for diagnostic or therapeutic services, the codes being distinguished from one another by the name of the nerve and whether a single or continuous infusion catheter is used, all injections into the nerve including branches described by the code descriptor constitutes to single unit of service’. I’m looking all for-. What I want to know, ‘Can I bill my fluoroscopic guidance with it?’.

As I keep looking, let’s see where else they have 644. I’m going to go a little farther down. That’s the paragraph we already read. Wow. Those are the only two that we have for that. There’s nothing here that says-. Let me make sure. Well if it’s used for an anesthetic procedure, we cannot unbundle it from anesthesia. We are not using it from anesthetic. We’re doing a nerve block. That is the procedure we’re performing. In that case, it’s not an anesthetic. If we’re doing it for moderate sedation, we’re not doing it from moderate sedation. Scroll down a little bit farther and see if there’s anywhere else that uses that code.  Let’s see. These codes describes services that may be utilized for postoperative pain management. Services described by these codes may be reported by the physician performing the operative procedure only if provided for purposes unrelated to post-op pain. Well, there’s nothing in the documentation that we looked at. When the person asked me, there no anything saying it was for post-op management. This was just a pain management procedure in a physician’s office and that’s the only thing they were doing. It wasn’t for post-op. It was not anything like that. Let’s see if there’s anything else. That’s our post-op pain management. That’s it. Then, it takes me back to the top.

The next thing I would do is-. Alright, I’ve looked at the injection code. Now, I’m going to go and make sure there isn’t anything around the fluoroscopic guidance that tells me I can’t report it. So that’s in my 70000. I’m going to go in my chapter 9 and open it. Let me get this. I’m going to look for the 77002. What I find is-. The very first one. There’s two page items that says, 77002 is part of a group of codes that describe radiological guidance. CMS allows for one unit of service for any of these codes at any single patient encounter regardless of the number of  placements performed. So no matter how many times they do it, they’re going to bill it one time. The units of service for this codes is the patient encounter not the number of lesions, aspirations, biopsies, injections or localizations. So we only get one unit. We understand that.

Let’s see what the other says. It says radiological supervision and interpretation codes include all radiological services necessary to complete the service. CPT codes for fluoroscopy or  fluoroscopic guidance or ultrasound guidance should not be reported separately from the radiological supervision and interpretation. That’s what they’re talking about. When you do this code, you’re doing all of that. You’re doing the localization and the reporting for it. Radiological guidance procedures include all include services necessary to complete the procedure. CPT codes for fluoroscopy should not be reported separately with fluoroscopic guidance procedure. CPT codes for ultrasound should not be reported separately with an ultrasound guidance procedure. It’s part of it. If you did fluoroscopic guidance, the fluoroscopy bundled. That’s what they’re saying there. Same thing for CT can’t be reported separately. All of that. If you were to read for the rest here, those are the only two matches the 77002.

I went a little bit farther and read even more into this different areas and what I actually found is in the 60000 series. Let me go back and pull that up. What I found  was that many of the codes in the same area as that branch code. That other peripheral nerve or branch in the anesthetic. The nerve block that they were doing. What I found is the reason that I believe that edit exists is if we were using some of the other codes in that area, like it says if lumbar plaques, posterior approach, continuous infusion by catheter. All of that. There is actually an edit in here that says, if you are doing an injection into the spine or into the epidural space that fluoroscopic guidance is not separately reportable according to Medicare.  So my response to the student who asked me the question, “Why is my provider putting a 59 on there?”, if you’re provider is putting a 59 when 64450 and 77002 are together, the documentation should clearly indicate that that injection because it says other peripheral branch was not made into the spine or epidural space. That’s what they’re doing. They’re saying,’This is not a spinal procedure so I should be able to report my fluoroscopy separately’. That’s why I say you really need to understand the manual that goes along with the NCCI edits in addition to your typical CPT roles. Those are all of the things that we can gain from all of these pages. There’s a ton of information in this NCCI policy manual. It’s updated at least annually. Like I said, the edit are updated quarterly. Usually they go along and make the same edits here in the manual. But they only update the manual every year so you make sure that you go back in checking that manual.

Wrap Up

So let’s wrap up a little bit. We covered a lot of information to today’s session of Did You Know segment, right? We talked about CCI and NCCI. Those national correct coding initiative edits. The reason they exist is to ensure proper code assignment and to safeguard against improper payments for not coding correctly, identifying what services are bundled together and when we can separate them and how we know to use certain modifiers.  The more familiar that you are with CCI and NCCI, the fewer denials you’re going to see right of the bat. The easier it’s going to be to work in edits when they go through that claims scrubbing software. But the other thing that will make it easier when you get a lot of denials because you should be able to look at the NCCI manual and for certain carrier you’re going to know why you get a denial. You’re going to hit an NCCI edit that you maybe didn’t have loaded in your front encoder coding system. It’ll become easier and easier to work which means cleaner claims going out the door, fewer denials. So you’re spending less time and money working your denials. You’re getting the correct payment and correct reporting right off the bat which makes everybody happier. It makes our lives’ a lot easier.

As we always say on Did You Know, these episodes are geared all around helping you learn things that you need to know to be able to do coding and coding related jobs well on the day out basis. As you’re getting into coding and billing and just this entire industry, you want to make sure that you’re demonstrating that you’re a self starter. Knowing that NCCI edits exist, knowing where the policy manual is, knowing how to use not only the code pair checking software but also those excel spreadsheets and what a column one is versus a column two, really give you a leg up on the other individuals who may not know that information. You’re going to be able to explain things to your provider and help save them money that you have otherwise know. You always want to be that self starter you’ll always want to be the one that people can go to for information and to help find what they’re looking for because there you can become an invaluable resource for so many other reasons. Remember that you are your own best resource.

You want to become more and more familiar with all of the different tools that will help you do your job to the best of your ability. Hopefully, this session here from CCO, on NCCI edits have been beneficial for you. You’ve learned what NCCI edits are. If you didn’t already know, you know where to find more information on them. You know how to check column one and column two edits even if you don’t have a code pair checking software. You know where to find that policy manual. You’ll read up on that and start learning what service are bundled together. I would definitely encourage you.

If you work in a specific specialty, atleast go out and look at the part of the NCCI policy manual that applies to the services that you report. If you work in gastroenterology, go out there and pull up those 40000 series codes and look and see what it says about bundling things together. I’ll guarantee it will open your eye and will give you a several ahuh moments as to why you’re getting denials or why can’t we bill certain things together without modifiers, why your providers are using certain modifiers. Those are all great things to be familiar with.

So again, hopefully this will help you out and you learned a little bit of something and we’ll  be happy to see you back again in next week for another Did You Know episode. If you missed one of our Did You Know episodes, don’t forget they’re always available on our Facebook page. Make sure that you’ve liked the CCO Facebook page. Check us out on Youtube as well. We look forward to seeing you then. Happy coding!


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