by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
May 20th, 2020
If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.
The use of Modifier 25 is one example that has general coding guidelines and rules, but there is not a CCI edit for every code it should be used with. This information can be found in the NCCI Edit Manual under Chapter I Section D, Evaluation and Management (E&M) Services. It is understood that an E&M service is separately reportable on the same date of service as a procedure with a global period of 000, 010, or 090 under limited circumstances.
NOTE: Some MACS such as Palmetto GBA state: "Modifier 25 should not be submitted with E/M codes that are explicitly for new patients only".
There are a few reasons CCI does not contain edits on this rule. One reason is all MAC's do not have the same edits - NCCI does not contain edits based on certain rules because MACs have separate edits. NCCI contains many, but not all, possible edits based on these principles.
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure, and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedures do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.
NCCI Policy: Chapter I Section D, Evaluation and Management (E&M) Services
NOTE: Be sure to check the date of service as CMS revised the NCCI edits April, 1 2020 with over 291,902 Procedure to Procedure (PTP) edits and 197 Medically Unlikely edits (MUE), if using Find-A-Code Be sure you have the correct Date selected under your viewing date.
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.