By Dirk Elston, MD, May 01, 2011
My claim was denied because of CCI edits and bundling. What does that even mean?
Bundling of services by “CCI edits” remains a top reason for claims to be denied. The National Correct Coding Initiative (CCI) was implemented in 1996 to prevent duplicate payment for services that should have been reported with a single code (bundled). For example, you may shave and curette a suspected basal cell carcinoma and send the specimen to the lab. If you hold the bill until the pathology report is received, you should bill only for the destruction of the malignancy. It would be inappropriate to report shave, biopsy, and destruction of the same lesion, and the CCI edits prevent such an error.
Similarly, certain cognitive services are already paid for as part of the procedure and should not be reported separately. Procedures with a global period typically have a follow-up visit already calculated into the value of the code. To prevent multiple payments for services that should be bundled, each Medicare carrier makes use of “CCI edits” in their claims processing system.
But what if I have to shave, biopsy, and destroy three separate lesions on the same day?
If you have treated three separate lesions, you need a mechanism to tell the carrier that the services were related to discrete lesions and should not be bundled together. In this case, modifier 59 allows you to override the CCI edit that would have inappropriately bundled the services.[pagebreak]
How Correct Coding Initiative (CCI) edits work
The software recognizes pairs of CPT or HCPCS Level II codes that are not separately payable except under special circumstances. All claims submitted by a single provider for the same beneficiary on the same date of service are compared to these CCI tables. There are two important CCI tables, Column 1/Column 2 edits and Mutually Exclusive Edits.
The column 1/column 2 edit table identifies column 2 (component) codes which are an integral part of the column 1 (comprehensive) codes and denies separate payment. If there is no reason to override the CCI edit with an appropriate modifier, only the column 1 code is paid.
Example: Excision of benign lesions includes simple closure. But, if a patient with a suspicious pigmented skin lesion on the arm also requires stitches for a cut on the leg, you should report the simple closure with a modifier 59.
The mutually exclusive edit table works in a similar fashion, but contains pairs of codes for procedures that cannot reasonably be performed together based on anatomy or code definitions. Usually this refers to two procedures that wouldn’t make sense if performed at the same anatomical location.
Example: If you curette a basal cell carcinoma to define its margins, then excise the lesion, you shouldn’t bill for destruction and excision of the same lesion. However, if you perform destruction (17261) and excision (11601) on two anatomically separate and distinct lesions, you should apply the 59 modifier to 11601 to override the mutually exclusive edit.
Key modifiers to override CCI edits
When separately identifiable medically necessary evaluation and management (E/M) services are provided along with a procedure on the same day of service, modifier 25 should be appended to override the CCI edit that would inappropriately bundle the services. Modifier 24 performs the same function during the global period following a procedure. Modifier 59 is used to prevent inappropriate bundling of a distinct procedural service independent from other procedural services performed on the same day. Modifier 79 performs the same function during the global period.
Examples: A patient has a basal cell carcinoma excised. He returns in seven days to have stitches removed and is told the lesion was completely excised. No E/M service should be billed.
A patient has a basal cell carcinoma excised. He returns in five days because of an outbreak of poison ivy. The E/M service should be reported with modifier 24.
How do I obtain the Correct Coding Initiative (CCI) Edits Manual?
The Correct Coding Initiative (CCI) Edits Manual is available at no cost through the CMS website at www.cms.hhs.gov/NationalCorrectCodInitEd/. Hard copies of the manual can be purchased via the National Technical Information Service (NTIS) website at www.ntis.gov/products/families/cci/, or by contacting NTIS at 1-800-363-2068 or 703-605-6060.
A free online tool to help physicians with integumentary system CCI edits is available at www.cms.gov/NationalCorrectCodInitEd/NCCIEP/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=2&sortOrder=ascending&itemID=CMS046396&intNumPerPage=10.