Revisiting Medicare’s Correct Coding Initiative

In 1996 Medicare introduced new software that allowed CMS contracted carriers to identify claims billed by providers or suppliers who were billing separately for items or services that should be represented with only one CPT code. Billing multiple CPT codes for a given service that should only be represented with a single code is referred to as unbundling. CMS publishes an updated list of coding pairs every 90 days referred to as the Correct Coding Initiative (CCI). Version 10.3 goes into effect on Oct. 1, 2004, and is in effect until Jan. 1, 2005. The current version in effect should always replace earlier versions. Outdated versions should be kept in a separate binder for referencing services provided in previous quarters. A key component of the CCI is the use of modifier -59. Modifier -59 was developed by CMS solely for use in conjunction with the CCI tables. First introduced by CMS in 1996 as a temporary modifier (-GB), it was officially introduced into the CPT book in 1997. Unfortunately, the majority of non-Medicare carriers do not recognize the -59 modifier which leads to many improperly denied claims. However, each year more carriers are adopting the Medicare unbundling edits so the future looks more promising. Per CPT 2004, the definition of modifier -59 states: “Distinct Procedural Service; under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstance. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed don the same day by the same physician.” There are two parts of the CCI versions — the narrative section and the actual table which lists the pairs that cannot be billed together on the same date of service for the same lesion, procedure, or site. Below are some common questions that are asked regarding the CCI, its edits and the use of modifier –59, which is required when listed pairs are unrelated and need a computer override to avoid denial. Q: Can you explain how the tables work? A: The CCI consists of a list of coding pairs. There are two columns indicated: a. Comprehensive Table (Also referred to as Column I) b. Mutually Exclusive Table (Also referred to as Column II) There is a CPT code listed in Column I and another CPT code listed in Column II. By “pairing” these two codes, Medicare is indicating to providers that the two services cannot be billed on the same date of service, for the same patient, for the same lesion, procedure or operative site. The comprehensive service (listed in Column I) includes the component service (listed in Column II). If however, the service in Column II is performed on a separate lesion, site, or done in conjunction with another surgical service both can be billed, but the service in Column II must be billed with modifier -59 or it will be denied. A few carriers allow the modifier to be placed on either code but the rule of thumb is that the -59 modifier should be added to the codes in Column II if they are unrelated. Q: The tables include a “standard policy statement” after each set of paired codes. What do these statements mean? A: When the CCI was initially published in the late 1990s, there were actually two separate tables. Each table gave a reason why the two codes could not be billed separately. Some of the comments are: • Mutually exclusive procedures • Misuse of Column 2 with Column 1 code • HCPCS/CPT coding manual instruction/guideline These policy statements refer to some sort of internal edits which really have no meaning to billing staff. The policy statements are derived from the narrative section which precedes the actual edit table. Whatever the comment is, the important thing that billing staff need to heed is that you can’t bill the code in Column II if it’s related to the service in Column I. For example: A dermatologist examines a patient with a non-healing lesion of the back which the physician is relatively certain is a Basal Cell Carcinoma. Because of the age of the patient and the location of the lesion, the decision is made to treat the lesion with curettage and electrodessication. CPT code 17263 is selected based on the size of the lesion. To confirm the diagnosis, a sample scraping (e.g., confirmative biopsy) is obtained and sent off for histologic evaluation. A biopsy is normally billed using CPT code 11100. Looking at the CCI table under 17263, you see code 11100 listed in Column II. Therefore, only the 17263 can be billed. Billing both the 11100 and the 17263 would be considered unbundling. Some staff bills both and receives a denial for code 11100. They discover that by adding a -59 modifier to 11100, payment for 11100 is made upon review. This is considered a false claim because the two services are related and from the same site. Adding a -59 modifier to CPT code 11100 indicates that the biopsy is from a different site/lesion which is not true. Had a biopsy been taken from a different lesion, adding a -59 modifier would be appropriate. Q: On the far right of the tables is a heading called “indicator”. There is a “1” or a “0” listed beside each of the coding pairs, what does this indicator code mean? A: When checking the Correct Coding Initiative Table for unbundling scenario, always be sure to check the indicator codes. 0 — Indicates that there are no circumstances in which a modifier would be appropriate. The use of the -59 modifier will not be appropriate. Even if the -59 modifier is attached to the code in Column II, the bundled code will still be denied. 1 — Indicates that a modifier is allowed in order to differentiate between the services provided. The use of the -59 modifier on the component code will allow an override of the computer edit and therefore result in payment. Be sure that the -59 modifier is only appended if the bundled pairs are unrelated services. Q: What benefit does the narrative section of the CCI version provide? A: First, be sure to obtain the dermatology specific version of the CCI. This eliminates having to read pages and pages of information that have nothing to do with dermatology. Chapter II of the CCI is dedicated to the integumentary system which includes CPT codes 10000 - 19999. (For information on obtaining quarterly CCI updates, call the Inga Ellzey Practice Group at 1-800-318-3271.) Reading the nine pages summarizes the basis for the edits and provides guidance to billers. I find the narrative extremely helpful when I do appeals to non-Medicare carriers. For example, under section J, #6, of the General Policy Statements, you’ll find the following comment: “The NCCI edits with column 1 CPT codes 17000 -17004 (destruction of benign or premalignant lesions) each with column 2 CPT codes 11100 (biopsy of single skin lesion) are often bypassed by utilizing modifier -59. Use of modifier -59 with the column 2 CPT code 11100 of these NCCI edits is only appropriate if the two procedures of a code pair edit are performed on separate lesions or at separate patient encounters.” Billers can use this official Medicare statement to appeal claims where the 11100 is denied when billed for an unrelated lesion on the same date of service that the destruction codes are billed. I find the attachment of this very helpful in getting the denial reversed. Inga Ellzey, President/CEO of the Inga Ellzey Practice Group, Inc., in Casselberry, FL., is an expert on dermatology coding, documentation and reimbursement. She has more than 29 years of experience in the field of dermatology and is also the CEO and founder of two nationwide dermatology billing services. You can phone her at (800)318-3271, or e-mail her at iellzey@iepg.com.