coding strategies

Keeping it All Together

Except when we’re not supposed to, of course.

JOHN RUMPAKIS, O.D., M.B.A.

Too often I receive e-mails from doctors about a claim denial due to performing services on the same date of service or because the insurance carrier bundles (often inappropriately) special ophthalmic procedures into office visit codes.

Knowing what services can be performed together on the same date of service is imperative in today’s healthcare environment.

The coding authority

The National Correct Coding Initiative (NCCI) was implemented in 1996 to assist physicians in correct coding. The policies are based on coding conventions as defined by the American Medical Association CPT manual.

The NCCI includes edits, which are pairs of CPT or HCPCS Level II codes, that are not separately payable except under certain or special circumstances. This “rule set” is applied to all services provided and billed by the same provider for the same beneficiary on the same date of service.

The two types of applied NCCI rules: Column 1 (Comprehensive)/Column 2 (Component) and Mutually Exclusive. If a CPT code in column 1 is billed on the same date of service by the same provider to the same patient as a “matched” column 2 code, the column 2 code will be denied. For example, if I tried to bill a 92250 (fundus photography) with a 99211 (visit for the evaluation and management of an established patient that may not require the physician’s presence), the 99211 code is deemed an existing component of the more comprehensive 92250 and would therefore be denied.

The Mutually Exclusive rule set is defined as services not reasonable for a physician to be performing on the same date of service, unless an appropriate modifier is used to explain extenuating circumstances. A common example of this: trying to bill for 92133 (OCT of the optic nerve) and 92250 on the same day. This particular combination is not allowed under the Mutually Exclusive rule set.

Extenuating circumstances, specific clinical situations, etc. confuse this matter even more.

NCCI modifiers

Extenuating circumstances, specific clinical situations and unique applications of the aforementioned rules among carriers confuse this matter even more. To handle these situations, use a specific group of modifiers to “override” a NCCI-based code pair denial. The following modifiers apply to our clinical practice: E1 through E4, LT, RT, 25, 79 and 59.

As the O.D., it is your responsibility to thoroughly know and understand the definition, rules and appropriate application of a modifier before using it. Many audit defenses with which I am involved as part of the defense team are based on the doctor’s incorrect use of modifiers.

Navigating code bundling

CPT code bundling is often very confusing and frustrating. However, web-based coding systems are available to instantly provide you with the rules on any CPT code combination. Also, some EHRs include automatic alerts when a CPT combination is incorrect.

Whether you master the NCCI Edits manually or you harness technology to help, it is critical to understand how they work and affect your clinical care and claim reimbursements. OM

DR. RUMPAKIS IS PRESIDENT AND CEO OF PRMI, A CONSULTING, APPRAISAL AND MANAGEMENT FIRM FOR HEALTHCARE PROFESSIONALS. HE’S DEVELOPED AN INTERNET-BASED CPT CODE SOFTWARE PROGRAM AND IS A PROLIFIC LECTURER ON THESE TOPICS. SEND COMMENTS TO OPTOMETRICMANAGEMENT@GMAIL.COM.