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Carol Pohlig

A hospitalist who scrutinizes claims might notice a payment denial related to “unbundling” issues. Line-item rejections might state the service is “mutually exclusive,” “incidental to another procedure,” or “payment was received as part of another service/procedure.” Unbundling refers to the practice of reporting each component of a service or procedure instead of reporting the single, comprehensive code. Two types of practices lead to unbundling: unintentional reporting resulting from a basic misunderstanding of correct coding, and intentional reporting to improperly maximize payment of otherwise bundled Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes.1

The initial NCCI goal was to promote correct coding methodologies and to control improper coding, which led to inappropriate payment in Part B claims.

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) for implementation and application to physician claims (e.g., Medicare Part B) with dates of service on or after Jan. 1, 1996. The rationale for these edits is a culmination of:

  • Coding standards identified in the American Medical Association’s (AMA) CPT manual;

  • National and local coverage determinations developed by CMS and local Medicare contractors;

  • Coding standards set forth by national medical organizations and specialty societies;

  • Appropriate standards of medical and surgical care; and

  • Current coding practices identified through claim analysis, pre- and post-payment documentation reviews, and other forms of payor-initiated audit.

FAQ

Q: Can a physician override NCCI edits?

A: Yes. NCCI code pairs are assigned a status. This status is identified as a code pair superscript. The code pair superscript can be 0, 1, or 9: “0” means that a modifier is not allowed at all, and will not override an edit; “1” means that a modifier is allowed, when appropriate, for two services or procedures that were performed at separate sessions or separate sites during the same session; and “9” means that the edit is no longer applicable.

The most common example of a hospitalist reporting two “bundled” services together occurs when an evaluation and management (E/M) service (e.g., 99233) is reported with a critical-care service (99291) on the same day by the same physician or physicians of the same specialty in a provider group. Per Medicare guidelines, both critical care and an E/M service can be paid, but only if the inpatient E/M service was furnished early in the day when the patient did not require critical care, yet required it later that same day.5

Alternatively, once critical care is initiated, any subsequent evaluations (on the same day) are counted toward critical-care time (as in the above scenario). After meeting the guidelines for reporting these two services together, the hospitalist appends modifier 25 to the “bundled” E/M: 99291, 99233-25. Documentation must support this situation, as it likely will need to be sent to the insurer before payment is obtained.

The initial NCCI goal was to promote correct coding methodologies and to control improper coding, which led to inappropriate payment in Part B claims.2 It later expanded to include corresponding NCCI edits in the outpatient code editor (OCE) for both outpatient hospital providers and therapy providers. Therapy providers encompass skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy (OPTs) and speech-language pathology providers, and home health agencies (HHAs).

Fact-Check

The NCCI recognizes two edit types: Column One/Column Two Correct Coding edits and Mutually Exclusive edits. Each of these edit categories lists code pairs that should not be reported together on the same date by either a single physician or physicians of the same specialty within a provider group.

 

 

When applying Column One/Column Two editing logic to physician claims, the Column One code represents the more comprehensive code of the pair being reported. The Column Two code (the component service that is bundled into the comprehensive service) will be denied. This is not to say a code that appears in Column Two of the NCCI cannot be paid when reported by itself on any given date. The denial occurs only when the component service is reported on the same date as the more comprehensive service.

For example, CPT code 36556 (insertion of nontunneled centrally inserted central venous catheter, age 5 years or older) is considered comprehensive to codes 36000 (introduction of needle or intracatheter, vein) and 36410 (venipuncture, age 3 years or older, necessitating physician’s skill [separate procedure], for diagnostic or therapeutic purposes). These code combinations should not be reported together on the same date when performed as part of the same procedure by the same physician or physicians of the same practice group. If this occurs, the payor will reimburse the initial service and deny the subsequent service. As a result, the first code received by the payor, on the same or separate claims, is reimbursed, even if that code represents the lesser of the two services.

Mutually Exclusive edits occur with less frequency than Column One/Column Two edits. Mutually Exclusive edits prevent reporting of two services or procedures that are highly unlikely to be performed together on the same patient, at the same session or encounter, by the same physician or physicians of the same specialty in a provider group. For example, CPT code 36556 (insertion of nontunneled centrally inserted central venous catheter, age 5 years or older) would not be reported on the same day as 36555 (insertion of nontunneled centrally inserted central venous catheter, younger than 5 years of age).

CMS publishes the National Correct Coding Initiative Coding Policy Manual for Medicare Services (www.cms.hhs.gov/NationalCorrectCodInitEd) and encourages local Medicare contractors and fiscal intermediaries to use it as a reference for claims-processing edits. The manual is updated annually, and the NCCI edits are updated quarterly. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.

References

  1. National correct coding initiative edits. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/NationalCorrectCodInitEd. Accessed March 10, 2009.

  2. Medicare claims processing manual. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 10, 2009.

  3. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press, 2008;477-481.

  4. Modifier 59 article. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf. Accessed March 10, 2009.

  5. French K. Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians. 2008;283-287.

Coding Reminder: Modifier 59

59: 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 and services that are not normally reported together but are appropriate under the circumstances.

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 on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59.

Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.4

Modifier 59 is the most frequently used NCCI-associated modifier, but it often is used incorrectly. For the NCCI, its primary purpose is to “unbundle” a service by indicating that two or more procedures are performed at different anatomic sites or different patient encounters on the same day by the same physician or physician of the same specialty in a provider group. It should only be used if no other modifier more appropriately describes the relationships of the procedure codes (e.g., modifier 25: significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).3

NCCI edits define when two procedure HCPCS/CPT codes may not be reported together, except under special circumstances. If an edit allows the use of NCCI-associated modifiers, the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or on different patient encounters.

Carrier processing systems utilize NCCI-associated modifiers to allow payment of both codes of an edit. Modifier 59 and other NCCI-associated modifiers should not be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.4

Issue
The Hospitalist - 2009(07)
Publications
The Hospitalist
Sections
Practice Economics
Managing Your Practice
Coding
Medicolegal Issues
Career
Practice Management
All Content
Author(s)
Carol Pohlig
Author(s)
Carol Pohlig

A hospitalist who scrutinizes claims might notice a payment denial related to “unbundling” issues. Line-item rejections might state the service is “mutually exclusive,” “incidental to another procedure,” or “payment was received as part of another service/procedure.” Unbundling refers to the practice of reporting each component of a service or procedure instead of reporting the single, comprehensive code. Two types of practices lead to unbundling: unintentional reporting resulting from a basic misunderstanding of correct coding, and intentional reporting to improperly maximize payment of otherwise bundled Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes.1

The initial NCCI goal was to promote correct coding methodologies and to control improper coding, which led to inappropriate payment in Part B claims.

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) for implementation and application to physician claims (e.g., Medicare Part B) with dates of service on or after Jan. 1, 1996. The rationale for these edits is a culmination of:

  • Coding standards identified in the American Medical Association’s (AMA) CPT manual;

  • National and local coverage determinations developed by CMS and local Medicare contractors;

  • Coding standards set forth by national medical organizations and specialty societies;

  • Appropriate standards of medical and surgical care; and

  • Current coding practices identified through claim analysis, pre- and post-payment documentation reviews, and other forms of payor-initiated audit.

FAQ

Q: Can a physician override NCCI edits?

A: Yes. NCCI code pairs are assigned a status. This status is identified as a code pair superscript. The code pair superscript can be 0, 1, or 9: “0” means that a modifier is not allowed at all, and will not override an edit; “1” means that a modifier is allowed, when appropriate, for two services or procedures that were performed at separate sessions or separate sites during the same session; and “9” means that the edit is no longer applicable.

The most common example of a hospitalist reporting two “bundled” services together occurs when an evaluation and management (E/M) service (e.g., 99233) is reported with a critical-care service (99291) on the same day by the same physician or physicians of the same specialty in a provider group. Per Medicare guidelines, both critical care and an E/M service can be paid, but only if the inpatient E/M service was furnished early in the day when the patient did not require critical care, yet required it later that same day.5

Alternatively, once critical care is initiated, any subsequent evaluations (on the same day) are counted toward critical-care time (as in the above scenario). After meeting the guidelines for reporting these two services together, the hospitalist appends modifier 25 to the “bundled” E/M: 99291, 99233-25. Documentation must support this situation, as it likely will need to be sent to the insurer before payment is obtained.

The initial NCCI goal was to promote correct coding methodologies and to control improper coding, which led to inappropriate payment in Part B claims.2 It later expanded to include corresponding NCCI edits in the outpatient code editor (OCE) for both outpatient hospital providers and therapy providers. Therapy providers encompass skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy (OPTs) and speech-language pathology providers, and home health agencies (HHAs).

Fact-Check

The NCCI recognizes two edit types: Column One/Column Two Correct Coding edits and Mutually Exclusive edits. Each of these edit categories lists code pairs that should not be reported together on the same date by either a single physician or physicians of the same specialty within a provider group.

 

 

When applying Column One/Column Two editing logic to physician claims, the Column One code represents the more comprehensive code of the pair being reported. The Column Two code (the component service that is bundled into the comprehensive service) will be denied. This is not to say a code that appears in Column Two of the NCCI cannot be paid when reported by itself on any given date. The denial occurs only when the component service is reported on the same date as the more comprehensive service.

For example, CPT code 36556 (insertion of nontunneled centrally inserted central venous catheter, age 5 years or older) is considered comprehensive to codes 36000 (introduction of needle or intracatheter, vein) and 36410 (venipuncture, age 3 years or older, necessitating physician’s skill [separate procedure], for diagnostic or therapeutic purposes). These code combinations should not be reported together on the same date when performed as part of the same procedure by the same physician or physicians of the same practice group. If this occurs, the payor will reimburse the initial service and deny the subsequent service. As a result, the first code received by the payor, on the same or separate claims, is reimbursed, even if that code represents the lesser of the two services.

Mutually Exclusive edits occur with less frequency than Column One/Column Two edits. Mutually Exclusive edits prevent reporting of two services or procedures that are highly unlikely to be performed together on the same patient, at the same session or encounter, by the same physician or physicians of the same specialty in a provider group. For example, CPT code 36556 (insertion of nontunneled centrally inserted central venous catheter, age 5 years or older) would not be reported on the same day as 36555 (insertion of nontunneled centrally inserted central venous catheter, younger than 5 years of age).

CMS publishes the National Correct Coding Initiative Coding Policy Manual for Medicare Services (www.cms.hhs.gov/NationalCorrectCodInitEd) and encourages local Medicare contractors and fiscal intermediaries to use it as a reference for claims-processing edits. The manual is updated annually, and the NCCI edits are updated quarterly. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.

References

  1. National correct coding initiative edits. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/NationalCorrectCodInitEd. Accessed March 10, 2009.

  2. Medicare claims processing manual. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 10, 2009.

  3. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press, 2008;477-481.

  4. Modifier 59 article. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf. Accessed March 10, 2009.

  5. French K. Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians. 2008;283-287.

Coding Reminder: Modifier 59

59: 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 and services that are not normally reported together but are appropriate under the circumstances.

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 on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59.

Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.4

Modifier 59 is the most frequently used NCCI-associated modifier, but it often is used incorrectly. For the NCCI, its primary purpose is to “unbundle” a service by indicating that two or more procedures are performed at different anatomic sites or different patient encounters on the same day by the same physician or physician of the same specialty in a provider group. It should only be used if no other modifier more appropriately describes the relationships of the procedure codes (e.g., modifier 25: significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).3

NCCI edits define when two procedure HCPCS/CPT codes may not be reported together, except under special circumstances. If an edit allows the use of NCCI-associated modifiers, the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or on different patient encounters.

Carrier processing systems utilize NCCI-associated modifiers to allow payment of both codes of an edit. Modifier 59 and other NCCI-associated modifiers should not be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.4

A hospitalist who scrutinizes claims might notice a payment denial related to “unbundling” issues. Line-item rejections might state the service is “mutually exclusive,” “incidental to another procedure,” or “payment was received as part of another service/procedure.” Unbundling refers to the practice of reporting each component of a service or procedure instead of reporting the single, comprehensive code. Two types of practices lead to unbundling: unintentional reporting resulting from a basic misunderstanding of correct coding, and intentional reporting to improperly maximize payment of otherwise bundled Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes.1

The initial NCCI goal was to promote correct coding methodologies and to control improper coding, which led to inappropriate payment in Part B claims.

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) for implementation and application to physician claims (e.g., Medicare Part B) with dates of service on or after Jan. 1, 1996. The rationale for these edits is a culmination of:

  • Coding standards identified in the American Medical Association’s (AMA) CPT manual;

  • National and local coverage determinations developed by CMS and local Medicare contractors;

  • Coding standards set forth by national medical organizations and specialty societies;

  • Appropriate standards of medical and surgical care; and

  • Current coding practices identified through claim analysis, pre- and post-payment documentation reviews, and other forms of payor-initiated audit.

FAQ

Q: Can a physician override NCCI edits?

A: Yes. NCCI code pairs are assigned a status. This status is identified as a code pair superscript. The code pair superscript can be 0, 1, or 9: “0” means that a modifier is not allowed at all, and will not override an edit; “1” means that a modifier is allowed, when appropriate, for two services or procedures that were performed at separate sessions or separate sites during the same session; and “9” means that the edit is no longer applicable.

The most common example of a hospitalist reporting two “bundled” services together occurs when an evaluation and management (E/M) service (e.g., 99233) is reported with a critical-care service (99291) on the same day by the same physician or physicians of the same specialty in a provider group. Per Medicare guidelines, both critical care and an E/M service can be paid, but only if the inpatient E/M service was furnished early in the day when the patient did not require critical care, yet required it later that same day.5

Alternatively, once critical care is initiated, any subsequent evaluations (on the same day) are counted toward critical-care time (as in the above scenario). After meeting the guidelines for reporting these two services together, the hospitalist appends modifier 25 to the “bundled” E/M: 99291, 99233-25. Documentation must support this situation, as it likely will need to be sent to the insurer before payment is obtained.

The initial NCCI goal was to promote correct coding methodologies and to control improper coding, which led to inappropriate payment in Part B claims.2 It later expanded to include corresponding NCCI edits in the outpatient code editor (OCE) for both outpatient hospital providers and therapy providers. Therapy providers encompass skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy (OPTs) and speech-language pathology providers, and home health agencies (HHAs).

Fact-Check

The NCCI recognizes two edit types: Column One/Column Two Correct Coding edits and Mutually Exclusive edits. Each of these edit categories lists code pairs that should not be reported together on the same date by either a single physician or physicians of the same specialty within a provider group.

 

 

When applying Column One/Column Two editing logic to physician claims, the Column One code represents the more comprehensive code of the pair being reported. The Column Two code (the component service that is bundled into the comprehensive service) will be denied. This is not to say a code that appears in Column Two of the NCCI cannot be paid when reported by itself on any given date. The denial occurs only when the component service is reported on the same date as the more comprehensive service.

For example, CPT code 36556 (insertion of nontunneled centrally inserted central venous catheter, age 5 years or older) is considered comprehensive to codes 36000 (introduction of needle or intracatheter, vein) and 36410 (venipuncture, age 3 years or older, necessitating physician’s skill [separate procedure], for diagnostic or therapeutic purposes). These code combinations should not be reported together on the same date when performed as part of the same procedure by the same physician or physicians of the same practice group. If this occurs, the payor will reimburse the initial service and deny the subsequent service. As a result, the first code received by the payor, on the same or separate claims, is reimbursed, even if that code represents the lesser of the two services.

Mutually Exclusive edits occur with less frequency than Column One/Column Two edits. Mutually Exclusive edits prevent reporting of two services or procedures that are highly unlikely to be performed together on the same patient, at the same session or encounter, by the same physician or physicians of the same specialty in a provider group. For example, CPT code 36556 (insertion of nontunneled centrally inserted central venous catheter, age 5 years or older) would not be reported on the same day as 36555 (insertion of nontunneled centrally inserted central venous catheter, younger than 5 years of age).

CMS publishes the National Correct Coding Initiative Coding Policy Manual for Medicare Services (www.cms.hhs.gov/NationalCorrectCodInitEd) and encourages local Medicare contractors and fiscal intermediaries to use it as a reference for claims-processing edits. The manual is updated annually, and the NCCI edits are updated quarterly. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.

References

  1. National correct coding initiative edits. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/NationalCorrectCodInitEd. Accessed March 10, 2009.

  2. Medicare claims processing manual. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 10, 2009.

  3. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press, 2008;477-481.

  4. Modifier 59 article. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf. Accessed March 10, 2009.

  5. French K. Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians. 2008;283-287.

Coding Reminder: Modifier 59

59: 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 and services that are not normally reported together but are appropriate under the circumstances.

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 on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59.

Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.4

Modifier 59 is the most frequently used NCCI-associated modifier, but it often is used incorrectly. For the NCCI, its primary purpose is to “unbundle” a service by indicating that two or more procedures are performed at different anatomic sites or different patient encounters on the same day by the same physician or physician of the same specialty in a provider group. It should only be used if no other modifier more appropriately describes the relationships of the procedure codes (e.g., modifier 25: significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).3

NCCI edits define when two procedure HCPCS/CPT codes may not be reported together, except under special circumstances. If an edit allows the use of NCCI-associated modifiers, the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or on different patient encounters.

Carrier processing systems utilize NCCI-associated modifiers to allow payment of both codes of an edit. Modifier 59 and other NCCI-associated modifiers should not be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.4

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