OU T PAT I E N T SU R G E RY MA G A Z I N E | JA N U A RY 20102

When Is It OK to Bypass Medicare Edits?Apply a modifier when it’s appropriate, not automatically.

Cristina Bentin, CCS-P, CPC-H, CMA

CODING & BILLING

Automatically applying a modifier every timeone’s allowed is a surefire way to leavemoney on the table. Just as it’s important

that your coders know when a combination ofcodes warrants a bundling edit, it’s crucial that theyknow when it’s OK to bypass an edit.

Exceptions to the ruleCertain code combinations may warrant an excep-tion based on clinical documentation. Many combi-nations of codes reflect a bundling edit, but a cor-rect coding modifier indicator (CCM) will let thecoder know whether a modifier may be applied tobypass the edits in cases, for example, when sur-geons perform separate and distinct procedures.

A correct coding modifier indicator of 1 indicatesthat you may bypass an edit with a modifier, thus let-ting you report both services. A correct coding mod-ifier indicator of 0 indicates that no separate pay-ment will be made regardless of the modifier youapply. A correct coding modifier indicator of 9 indi-cates that the bundling edit is no longer applicable.

When it comes to Medicare edits, coders have 2tendencies. They either err on the side of cautionwhen reviewing the edits or they don’t understandwhen they should append a modifier to the CPTcode to indicate a separate and distinct procedurethat would otherwise be considered bundled. Thebetter the coder knows the procedure and the moreshe understands the rationale behind the NationalCorrect Coding Initiative edits, the easier she’ll beable determine whether a modifier is applicable.

The NCCI was implemented to ensure consistentnational correct coding across different states andjurisdictions, and to minimize improper coding thatcould potentially lead to inappropriate reimburse-ment. The NCCI identifies coding combinations thatnormally shouldn’t be billed by the same providerfor the same patient on the same day. The NCCIedits consist of pairs of HCPCS codes that arearranged into 2 tables — the Column 1/Column 2Correct Coding Edits table and the MutuallyExclusive Edits table. A common mistake is to codewith a “quick fix” mentality. By this we mean over-looking the correct coding modifier indicator. Don’tcode with blinders on. A tendency of NCCI editsusers is to interpret the codes found in column 2 tobe bundled at all times with codes found in column1, thereby disregarding the CCM indicators. Anunderstanding of the rationale behind the edits willensure that correct coding becomes second nature.

Let’s look at a few specialties where misinterpret-ing the NCCI edits can mean a loss in facility fees:• Gastroenterology. Medicare edits bundle CPT45380 (Colonoscopy, flexible, proximal to splenicflexure; with biopsy, single or multiple) into CPT45385 (Colonoscopy, flexible, proximal to splenicflexure; with removal of tumor(s), polyp(s) orother lesion(s) by snare technique) but allows for amodifier (-59) if the biopsy of a polyp and theremoval of polyp by snare technique are 2 separateand distinct procedures performed on 2 separateand distinct lesions.

CPT 45385 = $380.23CPT 45380-59 = $380.23/2

BYPASS SURGERY Notunderstanding when tobypass an edit can hurtyour bottom line.

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3JA N U A RY 2010 | OU T PAT I E N T SU R G E RY MA G A Z I N E

• Pain management. Medicare edits bundle CPT64483 (Injection, anesthetic agent and/or steroid,transforaminal epidural; lumbar or sacral, singlelevel) into CPT 62311 (Injection, single, epidural orsubarachnoid; lumbar, sacral [caudal]) considering64483 as mutually exclusive. The correct codingmodifier indicator (1) allows for a modifier (-59) tobe appended to CPT 64483 when performed at a dif-ferent level than the injection reported by CPT 62311.The physician’s documentation should detail the spe-cific levels and regions he is entering and injecting.

CPT 62311 = $295.98CPT 64483-59 = $295.98/2

• Orthopedics. Medicare edits bundle CPT 29823(Arthroscopy, shoulder extensive debridement)into CPT 29824 (Arthroscopy, shoulder, surgical;distal claviculectomy) at this time but allows for a

modifier if the debridementis performed separate anddistinct from the distal clav-iculectomy.

A coder unfamiliar withthe Medicare edits and itsconventions might reportonly CPT 29824 since CPT29823 is listed in theMedicare edits as an integral

component despite operative documentation to thecontrary. On the flip side, a coder that understoodthe detailed operative description and understoodwhen to apply the -59 modifier would report bothCPT 29824 and 29823-59 and capture additional reim-bursement. An important note: Documentation mustdescribe extensive debridement in significant areas/sites separate and distinct from the area/site of thedistal claviculectomy in order to report both codes.

CPT 29823-59 = $1,588.70CPT 29824 = $1,070.42/2

• Orthopedics. Medicare edits bundles CPT 29807(Arthroscopy, shoulder, surgical; repair of SLAPlesion) into CPT 29806 (Arthroscopy, shoulder, sur-gical; capsulorrhaphy) at this time, but allows for amodifier (-59) if the surgeon performs specificarthroscopic SLAP repair separate and distinct fromthe arthroscopic capsulorrhaphy and the capsulor-

Applying a modifier to bypass theedits when a procedure is truly inte-gral to the main procedure. The appli-cation of the -59 modifier is applicableonly in certain circumstances. The over-use of the -59 is a red flag to Medicareand the OIG.

Applying a modifier when appli-cable (separate and distinct proce-dure) to the wrong code. The modifiershould be applied to the code found incolumn 2 since it is the code that isdeemed integral to the procedure undernormal circumstances.

Memorizing code-specific edits.CPT codes and NCCI edits are subjectto changes annually or quarterly somemorizing code pair edits would be anexhaustive and fruitless undertaking tosay the least.

Using obsolete edits. Whetherusing paper or electronic versions of theedits, coders should ensure the editsare updated quarterly. In addition,coders should maintain or have accessto previous quarterly edits in the eventcode selections need to be justified forclaims adjudication or the more omi-

nous audit rebuttals.Not considering additional

Medicare and NCCI Edits Resources.CMS provides an electronic version ofthe NCCI policy manual that containscoding guidelines and reporting policiesfor many common procedures. I recom-mend that you review applicable chap-ters in addition to the tables titledColumn 1/Column 2 and MutuallyExclusive.

— Cristina Bentin,CCS-P, CPC-H, CMA

Indicates that …… the edit may be bypassed with a modifier, thus

allowing both services to be reported.… no separate payment will be made regardless

of the application of a modifier.… the bundling edit is no longer applicable.

Correct coding modifier indicator

1

0

9

Bypassing the Bundling Edit

Avoid These 5 Common Coding Mistakes

CODING & BILLING

rhaphy is unrelated to theSLAP repair. Use cautionwhen considering the appli-cation of a modifier.Remember the terms “sepa-rate” and “distinct.”

CPT 29806 = $1588.70CPT 29807-59 = $1,588.70/2

Medical necessityWhile we may have navigat-ed through our decision-making processes, let’s notforget that medical necessi-ty requirements will play arole in reimbursement.Local coverage determination policies provide doc-umentation and medical necessity essentials forspecific procedures. Your Medicare AdministrativeContractor/Fiscal Intermediary may offer LCD poli-cies that provide more specific coding, reporting

and medical necessitydirectives for more com-mon procedures. Whenyou combine a workingknowledge of the NCCIedits and CPT codingguidelines with detailedclinical documentation/medical record keeping,coders should be confidentwith final code selections.It will be these veryresources and directivesthat will serve as back upshould the coder need toshow credible documenta-

tion supporting the decision making process. OSM

Ms. Bentin (cristina@ccmpro.com) is the owner of CodingCompliance Management, a healthcare consulting company basedin Baton Rouge, La.

4 OU T PAT I E N T SU R G E RY MA G A Z I N E | JA N U A RY 2010

5 Questions to Ask When Coding Medicare Cases

1. Is the operative report coded correctly?

2. Is there an NCCI edit for these code sets?

3. What is the rationale behind the edit?

4. Does the correct code modifier indicator reflect that an edit may be bypassed with an appropriate modifier?

If so, which modifier is the most appropriate?

5. Should the edit be bypassed (as in the case of a separate and distinct procedure) simply because the

correct coding modifier indicator allows it?