Many of you are aware that the Central Office on HCPCScannot address any coverage or payment policy issues. As we all are aware, however, coding directly affects payment. The purpose of this article is to help explain (without getting too much into payment) why the National Correct Coding Initiative (NCCI) edits and the Outpatient Code Editor (OCE) were developed and how the NCCI edits and the OCE edits affect how facilities assign HCPCS/CPT codes for procedures and services provided. There are 2 sets of NCCI edits, one set is utilized for hospital reporting and the other set for physician reporting. NCCI edits apply to services performed by the same provider on the same date of service to the same beneficiary.
The Centers for Medicare & Medicaid Services (CMS) developed the NCCI as a way to promote correct coding nationally and to control improper coding (i.e., unbundling) of HCPCS/CPT codes which leads to inappropriate reimbursement or claim denial. The coding policies and edits are based on a variety of resources, which include, but are not limited to, the following:
- American Medical Association’s (AMA) Current Procedural Terminology (CPT) Manual coding conventions,
- Medical and surgical coding practice standards,
- National or specialty societies coding guidelines,
- National Medicare policies and edits, and
- Current coding practice.
There are two major types of NCCI edits: Column 1/Column 2 Correct Coding Edits and Mutually Exclusive Code (MEC) Edits. The Column 1/Column 2 Correct Coding Edits identify code combinations of Column 1 and Column 2 codes that should not be reported together. Although the two codes in some code pairs have a relationship such that the column two code is a component of the column one code, there are many additional reasons why two codes should not be reported together. Mutually exclusive edit pairs are procedures or services that cannot reasonably be performed at the same session. All NCCI edits allow payment for only the code in Column 1. Modifier indicators of “0,” “1,” or “9” are assigned to all code pairs in the Column 1/ Column 2 and MEC edit tables. These indicators identify whether a modifier can be appended to one of the codes in a code pair. The “0” indicator means a modifier is not allowed, and there are no circumstances where both codes of the code pair should be paid. Indicator “1” means a modifier is allowed when appropriate, allowing both codes of the edit to be potentially payable. The “9” indicator is used for deleted code pairs where the deletion date was retroactive to the effective date. The “9”indicator for all practical purposes can be ignored.
The hospital version of the OCE edits is utilized by fiscal intermediaries and Medicare Administrative Contractors (MACs) to process hospital outpatient services under the Outpatient Prospective Payment System (OPPS). These edits determine which codes are payable under the hospital OPPS. The OCE edits are arranged in numerical order and have descriptions and claim dispositions for each edit. There are differences between facility and professional services, and the code pairs and bypass modifiers in the OCE may be different from the NCCI.
Although NCCI edits capture a majority of CPT code pair combinations that should not be reported together, there are other code pair combinations, not included in the NCCI tables, that should not be reported together, and therefore, are not separately reportable. An example of this is “separate procedure” codes. There are some CPT codes that the American Medical Association designates as “separate procedures.” This designation is given to certain codes to identify services that are commonly carried out as a component of a more comprehensive procedure or service. An NCCI edit may or may not exist for a “separate procedure” code reported with a more comprehensive procedure code. Therefore, when coding for outpatient services, it is important to follow not only the NCCI edits but to also follow CPT and CMS NCCI edit guidelines for the appropriate reporting of “separate procedure” codes. These guidelines can be found in the beginning of each section of the CPT code book (i.e. surgery section, radiology section) and in the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1 and surgical chapters.
A CPT code that has a separate procedure designation should not be separately reported when it is considered an integral component of another procedure or service. CMS interprets the “separate procedure” designation as prohibiting the reporting of a separate procedure code when the procedure is performed with another procedure in an anatomically related region, generally, but not always, through the same skin incision, same orifice, or via the same surgical approach.
If a CPT code descriptor includes the term “separate procedure”, the CPT code may not be reported separately with a related procedure. CMS interprets this designation to prohibit the separate reporting of a “separate procedure” when performed with another procedure in an anatomically related region often through the same skin incision, orifice, or surgical approach. A CPT code with the “separate procedure” designation may be reported with another procedure if it is performed at a separate patient encounter on the same date of service or at the same patient encounter in an anatomically unrelated area often through a separate skin incision, orifice, or surgical approach. Modifier 59 or a more specific modifier (e.g., anatomic modifier) may be appended to the “separate procedure” CPT code to indicate that it qualifies as a separately reportable service. In these instances, it may be necessary to append Modifier 59, Distinct Procedural Service, to indicate that the “separate procedure” code qualifies as a separately reportable service. For example, if a “separate procedure” is performed during the same encounter in a different site or organ system, via a separate incision, it would be appropriate to report both procedure codes. If an edit occurs, modifier 59 may be appended to bypass the edit (if no other modifier is appropriate).
Although most HCPCS/CPT code defined procedures include services that are integral to them, it should be noted that some services are integral to a large numbers of procedures, while other services are integral to a more limited number of procedures. Listed below are a few examples of services that are integral to a large number of procedures:
- Cleansing, shaving and prepping of skin
- Draping and positioning of patient
- Insertion of intravenous access for medication administration
- Insertion of urinary catheter
- Sedative administration by the physician performing a procedure
- Local, topical or regional anesthesia administered by the physician performing the procedure
- Surgical approach including identification of anatomical landmarks, incision, evaluation of the surgical field, debridement of traumatized tissue, lysis of adhesions, and isolation of structures limiting access to the surgical field such as bone, blood vessels, nerve, and muscles including stimulation for identification or monitoring
- Surgical cultures
- Wound irrigation
- Insertion and removal of drains, suction devices, and pumps into same site
- Surgical closure and dressings
- Application, management, and removal of postoperative dressings and analgesic devices (peri-incisional)
- TENS unit
- Institution of Patient Controlled Anesthesia
- Preoperative, intraoperative and postoperative documentation, including photographs, drawings, dictation, or transcription as necessary to document the services provided
- Surgical supplies, except for specific situations where CMS policy permits separate payment
The Centers for Medicare & Medicaid Services (CMS) has provided many examples of the correct coding and reporting of these services. These examples can be accessed at http://www.cms.hhs.gov/NationalCorrectCodInitEd.
Now let’s take a look at a few of the examples below:
Incision and drainage services, as related to the integumentary system, generally involve cutaneous or subcutaneous drainage of cysts, pustules, infections, hematomas, abscesses, seromas or fluid collections.
If it is necessary to incise and/or drain a lesion as part of another procedure or in order to gain access to an area for another procedure, the incision and/or drainage is not separately reportable if performed at the same patient encounter.
For Example: A physician excising pilonidal cysts and/or sinuses (CPT codes 11770-11772) may incise and drain one or more of the cysts. It is inappropriate to report CPT code 10080 or 10081 separately for the incision and drainage of the pilonidal cyst(s).
A diagnostic endoscopy is not separately reportable with a surgical endoscopy per CPT Manual instructions. If an endoscopic procedure fails and is converted into an open procedure, the endoscopic procedure is not separately reportable with the open procedure.
For Example: A patient presents with aspiration of a foreign body. A bronchoscopy is performed identifying lobar foreign body obstruction, and an attempt is made to remove this obstruction bronchoscopically. It would be inappropriate to report CPT codes 31622 (diagnostic bronchoscopy) and 31635 (surgical bronchoscopy with removal of foreign body). Only the “surgical” endoscopy, CPT code 31635, may be reported. In this example, if the endoscopic effort fails and a thoracotomy is performed, the diagnostic bronchoscopy may be reported separately in addition to the thoracotomy. Modifier 58 may be used to indicate that the diagnostic bronchoscopy and the thoracotomy are staged or planned procedures. However, the CPT code for the surgical bronchoscopy to remove the foreign body is not separately reportable because the procedure was converted to an open procedure. If the surgeon decides to repeat the bronchoscopy after induction of general anesthesia to confirm the surgical approach to the foreign body, this confirmatory bronchoscopy is not separately reportable although the initial diagnostic bronchoscopy may still be reportable.
Endoscopic procedures include all minor related functions performed at the same encounter. Although CPT codes may exist to describe these functions, they should not be reported separately.
For Example: Transurethral resection of the prostate includes meatotomy, urethral calibration and/or dilation, urethroscopy, and cystoscopy. Codes for the included procedures should not be reported separately.
If two procedures are performed at the same anatomic site and same patient encounter, one procedure may be bundled into the other. (e.g., one procedure may be integral to the other.) However, if the two procedures are performed at separate anatomic sites or at separate patient encounters, they may be separately reportable. Modifier 59 may be reported to indicate that the two procedures are distinct and separately reportable services under these circumstances.
For Example: A patient with an open head injury and a contrecoup subdural hematoma requires an exploratory craniectomy for the open head injury and a burr hole drainage on the contralateral side for a subdural hematoma. The creation of a burr hole at the site of the exploratory craniectomy would be considered integral to the craniectomy. However, the contralateral burr hole drainage is a separate service not integral to the exploratory craniectomy. To correctly report the burr hole drainage for the contralateral subdural hematoma and the exploratory craniectomy, the burr hole should be reported with the appropriate modifier (e.g., 59, RT, LT). In this example the correct coding would be CPT codes 61304 (exploratory craniectomy) with one unit of service and 61154-59 (burr hole with drainage of subdural hematoma) with one unit of service.