Established by the Centers for Medicare and Medicaid Services (CMS), the National Correct Coding Initiative (NCCI) is in place to promote uniform coding and control unbundled coding. The Centers for Medicare and Medicaid Services incorporated medically unlikely edits in the NCCI program, and most of those edits are administered by Medicare Part B carriers.
Initially, NCCI edits were based on the 1994 Current Procedural Terminology (CPT) manual and Healthcare Common Procedure Coding System (HCPCS) level II code. Now, these edits are reviewed every quarter, and will use the American Medical Association’s CPT manual and CMS’s HCPCS level II code descriptors as references.
The NCCI edits are revealed in four versions annually (January 1, April 1, July 1, October 1). All local carriers should follow the most recent guidelines, even though their systems always lag behind current changes. The basis of this policy is: “Procedures should be reported with the most comprehensive CPT code that describes the services performed.”
You should not be using multiple codes by fragmenting procedures into component parts. For example, if you perform an upper GI endoscopy with biopsy of the stomach, you can only bill upper GI endoscopy with biopsy (CPT Code 43239). You should not bill upper GI endoscopy (CPT Code 43235) and stomach biopsy (CPT Code 43600) separately.1
NCCI Edits That Pertain to Dermatology
Let’s take a look at examples that are pertinent in dermatology:
Example I: A patient comes in with a lesion that looks like a basal cell carcinoma on the face. First you biopsy it and then you C&D. You should not be billing this encounter as a biopsy and destruction of a malignant lesion. You can only bill the destruction of a malignant lesion. (Of course, you have to wait for the histology to confirm a malignancy.)
Example II: You have a patient with a plantar wart that you first pare and then freeze. You cannot bill both paring (CPT Code 11055) and then destruction of benign lesion (CPT Code 17110). You should only bill the most comprehensive component of the treatment, which is the cryosurgery of the benign lesion in this case (CPT Code 17110).
Example III: You have a patient with genital warts. You first apply podophyllin and then you freeze the warts. You cannot bill chemical destruction of benign lesion of penis (CPT Code 54050) and cryosurgery of benign lesion of penis (CPT Code 54056).
Example IV: If you perform a skin biopsy, you cannot separately bill local anesthesia. Skin biopsy (CPT code 11100) includes the local anesthesia process.
Understanding NCCI Edit Indicators
Each NCCI edit has an indicator. Indicator of 0 means that NCCI edit cannot be bypassed under any circumstances. One example of this would be prostate surgery for a female patient! An indicator of 1 means that NCCI edit can be bypassed under given conditions with the appropriate modifier, such as -59.
Let’s take that patient in example I where you had a C&D of a BCC and a biopsy. If this patient already had a biopsy-proven BCC on his nose from a previous visit and returns for a scheduled treatment of that BCC on the nose and then he shows you another suspicious spot on his back, then you can biopsy that lesion at the same time and bill for both procedures using modifier -59, which means that these are two different and distinct procedures on two separate lesions.
Excision of malignant and benign lesions includes simple closure (CPT Code 12001-12018), strip closure or dressing changes, and they cannot be billed separately. However, intermediate (CPT Code 12031-12053) or complex repairs (CPT Code13100-13153) can be billed separately.
One important point to remember is that excision of benign lesions of 0.5 cm or less (CPT Code 11400) includes all kinds of repairs (simple, intermediate, complex).
Some CPT codes are used quite frequently together such as 11055-11057 (paring or cutting of benign hyperkeratotic lesion) and 11720-11721 (nail debridement by any method). They can be billed with modifier -59 as long as they are performed on separate nails.
How the Edit Works
Let’s take a look how the edit works. CPT Code 14000 is the adjacent tissue transfer code on the trunk for lesions up to 102 cm. You cannot bill any excision or biopsy codes with this procedure. However, you can see that it has an indicator of 1, which means you can do any of these procedures on two different lesions and bill them with modifier -59 as long as it’s not the same area where you performed the flap. (See Table I.)
Arming Yourself with the Right Information
This information will help you to fight the third-party payers when your claims get rejected for unbundling. You can obtain NCCI edits electronically or in hard copy. They are available for all major organ systems separately, so you can get chapter II by itself for integumentary codes (10000-19999).
Established by the Centers for Medicare and Medicaid Services (CMS), the National Correct Coding Initiative (NCCI) is in place to promote uniform coding and control unbundled coding. The Centers for Medicare and Medicaid Services incorporated medically unlikely edits in the NCCI program, and most of those edits are administered by Medicare Part B carriers.
Initially, NCCI edits were based on the 1994 Current Procedural Terminology (CPT) manual and Healthcare Common Procedure Coding System (HCPCS) level II code. Now, these edits are reviewed every quarter, and will use the American Medical Association’s CPT manual and CMS’s HCPCS level II code descriptors as references.
The NCCI edits are revealed in four versions annually (January 1, April 1, July 1, October 1). All local carriers should follow the most recent guidelines, even though their systems always lag behind current changes. The basis of this policy is: “Procedures should be reported with the most comprehensive CPT code that describes the services performed.”
You should not be using multiple codes by fragmenting procedures into component parts. For example, if you perform an upper GI endoscopy with biopsy of the stomach, you can only bill upper GI endoscopy with biopsy (CPT Code 43239). You should not bill upper GI endoscopy (CPT Code 43235) and stomach biopsy (CPT Code 43600) separately.1
NCCI Edits That Pertain to Dermatology
Let’s take a look at examples that are pertinent in dermatology:
Example I: A patient comes in with a lesion that looks like a basal cell carcinoma on the face. First you biopsy it and then you C&D. You should not be billing this encounter as a biopsy and destruction of a malignant lesion. You can only bill the destruction of a malignant lesion. (Of course, you have to wait for the histology to confirm a malignancy.)
Example II: You have a patient with a plantar wart that you first pare and then freeze. You cannot bill both paring (CPT Code 11055) and then destruction of benign lesion (CPT Code 17110). You should only bill the most comprehensive component of the treatment, which is the cryosurgery of the benign lesion in this case (CPT Code 17110).
Example III: You have a patient with genital warts. You first apply podophyllin and then you freeze the warts. You cannot bill chemical destruction of benign lesion of penis (CPT Code 54050) and cryosurgery of benign lesion of penis (CPT Code 54056).
Example IV: If you perform a skin biopsy, you cannot separately bill local anesthesia. Skin biopsy (CPT code 11100) includes the local anesthesia process.
Understanding NCCI Edit Indicators
Each NCCI edit has an indicator. Indicator of 0 means that NCCI edit cannot be bypassed under any circumstances. One example of this would be prostate surgery for a female patient! An indicator of 1 means that NCCI edit can be bypassed under given conditions with the appropriate modifier, such as -59.
Let’s take that patient in example I where you had a C&D of a BCC and a biopsy. If this patient already had a biopsy-proven BCC on his nose from a previous visit and returns for a scheduled treatment of that BCC on the nose and then he shows you another suspicious spot on his back, then you can biopsy that lesion at the same time and bill for both procedures using modifier -59, which means that these are two different and distinct procedures on two separate lesions.
Excision of malignant and benign lesions includes simple closure (CPT Code 12001-12018), strip closure or dressing changes, and they cannot be billed separately. However, intermediate (CPT Code 12031-12053) or complex repairs (CPT Code13100-13153) can be billed separately.
One important point to remember is that excision of benign lesions of 0.5 cm or less (CPT Code 11400) includes all kinds of repairs (simple, intermediate, complex).
Some CPT codes are used quite frequently together such as 11055-11057 (paring or cutting of benign hyperkeratotic lesion) and 11720-11721 (nail debridement by any method). They can be billed with modifier -59 as long as they are performed on separate nails.
How the Edit Works
Let’s take a look how the edit works. CPT Code 14000 is the adjacent tissue transfer code on the trunk for lesions up to 102 cm. You cannot bill any excision or biopsy codes with this procedure. However, you can see that it has an indicator of 1, which means you can do any of these procedures on two different lesions and bill them with modifier -59 as long as it’s not the same area where you performed the flap. (See Table I.)
Arming Yourself with the Right Information
This information will help you to fight the third-party payers when your claims get rejected for unbundling. You can obtain NCCI edits electronically or in hard copy. They are available for all major organ systems separately, so you can get chapter II by itself for integumentary codes (10000-19999).
Established by the Centers for Medicare and Medicaid Services (CMS), the National Correct Coding Initiative (NCCI) is in place to promote uniform coding and control unbundled coding. The Centers for Medicare and Medicaid Services incorporated medically unlikely edits in the NCCI program, and most of those edits are administered by Medicare Part B carriers.
Initially, NCCI edits were based on the 1994 Current Procedural Terminology (CPT) manual and Healthcare Common Procedure Coding System (HCPCS) level II code. Now, these edits are reviewed every quarter, and will use the American Medical Association’s CPT manual and CMS’s HCPCS level II code descriptors as references.
The NCCI edits are revealed in four versions annually (January 1, April 1, July 1, October 1). All local carriers should follow the most recent guidelines, even though their systems always lag behind current changes. The basis of this policy is: “Procedures should be reported with the most comprehensive CPT code that describes the services performed.”
You should not be using multiple codes by fragmenting procedures into component parts. For example, if you perform an upper GI endoscopy with biopsy of the stomach, you can only bill upper GI endoscopy with biopsy (CPT Code 43239). You should not bill upper GI endoscopy (CPT Code 43235) and stomach biopsy (CPT Code 43600) separately.1
NCCI Edits That Pertain to Dermatology
Let’s take a look at examples that are pertinent in dermatology:
Example I: A patient comes in with a lesion that looks like a basal cell carcinoma on the face. First you biopsy it and then you C&D. You should not be billing this encounter as a biopsy and destruction of a malignant lesion. You can only bill the destruction of a malignant lesion. (Of course, you have to wait for the histology to confirm a malignancy.)
Example II: You have a patient with a plantar wart that you first pare and then freeze. You cannot bill both paring (CPT Code 11055) and then destruction of benign lesion (CPT Code 17110). You should only bill the most comprehensive component of the treatment, which is the cryosurgery of the benign lesion in this case (CPT Code 17110).
Example III: You have a patient with genital warts. You first apply podophyllin and then you freeze the warts. You cannot bill chemical destruction of benign lesion of penis (CPT Code 54050) and cryosurgery of benign lesion of penis (CPT Code 54056).
Example IV: If you perform a skin biopsy, you cannot separately bill local anesthesia. Skin biopsy (CPT code 11100) includes the local anesthesia process.
Understanding NCCI Edit Indicators
Each NCCI edit has an indicator. Indicator of 0 means that NCCI edit cannot be bypassed under any circumstances. One example of this would be prostate surgery for a female patient! An indicator of 1 means that NCCI edit can be bypassed under given conditions with the appropriate modifier, such as -59.
Let’s take that patient in example I where you had a C&D of a BCC and a biopsy. If this patient already had a biopsy-proven BCC on his nose from a previous visit and returns for a scheduled treatment of that BCC on the nose and then he shows you another suspicious spot on his back, then you can biopsy that lesion at the same time and bill for both procedures using modifier -59, which means that these are two different and distinct procedures on two separate lesions.
Excision of malignant and benign lesions includes simple closure (CPT Code 12001-12018), strip closure or dressing changes, and they cannot be billed separately. However, intermediate (CPT Code 12031-12053) or complex repairs (CPT Code13100-13153) can be billed separately.
One important point to remember is that excision of benign lesions of 0.5 cm or less (CPT Code 11400) includes all kinds of repairs (simple, intermediate, complex).
Some CPT codes are used quite frequently together such as 11055-11057 (paring or cutting of benign hyperkeratotic lesion) and 11720-11721 (nail debridement by any method). They can be billed with modifier -59 as long as they are performed on separate nails.
How the Edit Works
Let’s take a look how the edit works. CPT Code 14000 is the adjacent tissue transfer code on the trunk for lesions up to 102 cm. You cannot bill any excision or biopsy codes with this procedure. However, you can see that it has an indicator of 1, which means you can do any of these procedures on two different lesions and bill them with modifier -59 as long as it’s not the same area where you performed the flap. (See Table I.)
Arming Yourself with the Right Information
This information will help you to fight the third-party payers when your claims get rejected for unbundling. You can obtain NCCI edits electronically or in hard copy. They are available for all major organ systems separately, so you can get chapter II by itself for integumentary codes (10000-19999).
