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How to use coding 'edits' to prevent billing problems

From the November ACP Observer, copyright 2003 by the American College of Physicians.

By Brett Baker

Q: Is it true that Medicare now makes its correct coding initiative (CCI) edits available on the Web at no cost?

A: The Centers for Medicare and Medicaid Services (CMS) recently posted its Medicare CCI coding "edits" on the Web. These edits are pairs of codes that Medicare will not pay when billed by the same physician on the same date of service for the same patient.

The decision to put these edits online is important, because physicians previously had to pay $300 a year for a print version or $260 a year for an electronic version. The CMS' decision to post the information is a result of ACP advocacy, with the College arguing that it was unfair to require physicians to purchase Medicare's rules.

Q: How do the CCI edits work and how do specific code combinations appear on the Web site?

A: The CMS developed the CCI edits to promote national coding methodologies to reduce improper coding. The edits are based on Current Procedural Terminology (CPT) coding conventions as well as current standards of medical and surgical coding practices. The electronic tables containing the CCI edits are updated on a quarterly basis, making it easier for physicians to keep current.

There are two types of edits that appear on the Web site:

  • Column 1/column 2 code edits. These pairings represent a procedure or service that is part of a more comprehensive procedure or service. (These edits were formerly known as "comprehensive/component edits.")

    The column 1 code represents the major procedure (the comprehensive code), while the column 2 code represents the minor procedure (the component). Medicare will pay only for the item in the column 1 code, because it generally represents the code with the higher payment rate.

    For an example of column 1/column 2 code edits, see "A sample of Medicare's CCI coding 'edits' " on this page.

  • Mutually exclusive code edits. Mutually exclusive codes represent procedures or services that could not reasonably be performed together during the same session (on the same date) by the same physician for the same beneficiary. (Medicare uses code definitions or anatomic considerations to determine when different codes could not be performed together.)

    Medicare pays the lower paying of the two codes in these combinations to give physicians an incentive to code correctly. ACP has argued that this policy is punitive—and inappropriate, because the remittance notice the physician receives from the Medicare carrier explaining the payment decision is too vague. Despite ACP's objections, however, Medicare has maintained this policy.

Q: Can I use modifiers to prevent a CCI edit from being applied to my charges?

A: A CPT or Healthcare Common Procedure Coding System (HCPCS) modifier will override a CCI edit when clinical circumstances warrant. To determine if a modifier can be used with certain code combinations, look at the column "modifier indicator" for instructions. The number "0" indicates that a modifier is not allowed; the number "1" means a modifier is allowed; and the number "9" means a modifier is not applicable.

Q: How can I tell when my Medicare charges have been affected by a CCI edit?

A: A CCI edit may have affected your claim if the remittance notice states one of the following:

  • Claim adjustment reason code B15, "claim/service denied/reduced because this service/procedure is not paid separately," and remark code M80, "we cannot pay for this when performed during the same session as another approved service for this beneficiary."

  • Claim adjustment reason code B10, "allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test," and remark code M80, "we cannot pay for this when performed during the same session as another approved service for this beneficiary."

Although the above remittance notice messages are also used to convey information unrelated to CCI edits, you can also use the information on the Web to determine if a CCI edit did play a role in a payment decision. Identifying when your carrier has applied CCI edits will help you decide whether to change your billing practice. You may need to include an appropriate modifier, appeal the Medicare payment decision, and/or complain to Medicare that an edit is inappropriate.

Q: Can you appeal a claims payment decision involving CCI edits, and how does Medicare handle those appeals?

A: You can appeal a payment decision involving a CCI edit. The CMS tells employees of the carriers that review claims to change the initial payment determination if the applicable CCI edit can be overridden by a modifier, even when physicians don't use modifiers themselves.

If a review process upholds the initial payment decision, your carrier must include a detailed explanation of the applicable CCI edit. The carrier must also reiterate one of the remittance notice messages stated above.

Q: What other type of information is included on the Medicare CCI Web site?

A: In addition to specific CCI edits, the CMS CCI Web site contains three sections: a CMS policy manual for Medicare Part B carriers; relevant Medicare regulations from the "Medicare Carriers Manual," section 4630; and CCI questions and answers.

This last part of the Web site offers guidance on contesting edits in the "How To Obtain Assistance With Questions Related to CCI Edits" section. Submit your concerns in writing to National Correct Coding Initiative, AdminaStar Federal Inc., P.O. Box 50469, Indianapolis, IN 46250-0469.

When submitting written concerns, please copy ACP at ACP, Attention: Carol McKenzie, 2011 Pennsylvania Avenue NW, Suite 800, Washington, DC 20006.

Brett Baker is a third-party payment specialist in the College's Washington office.

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