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The CCI Edits

Knowing these important rules can help reduce your denied claims.

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

One of the most frequent questions or comments I get during my medical coding and compliance lectures surrounds performing combinations of certain codes together on the same date of service by the same physician.

The rule set that governs this area of practice is called the National Correct Coding Initiative (NCCI) and more specifically, the Correct Coding Initiative (CCI) Edits.

What are the rules?

The NCCI, also known as CCI, was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment.

NCCI code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.

In addition to code pair edits, the NCCI includes a set of edits known as Medically Unlikely Edits (MUEs). A MUE is a maximum number of Units of Service allowable under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a provider on a date of service for a single beneficiary.

These rules, published by CMS, generally apply to all third-party carriers. Coding decisions for edits are based on conventions defined in the American Medical Association’s (AMA’s) “CPT Manual,” national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices and a review of current coding practices.

A modifier can be used to override, should medical necessity dictate it.

Prior to the implementation of MUEs, the proposed edits are released for review and comment to the AMA, national medical/surgical societies, and other national health care organizations, including non-physician professional societies, hospital organizations, laboratory organizations and durable medical equipment organizations.

Similarly, proposed NCCI edits are released to various national healthcare organizations for review and comment prior to implementation.

How do we apply the rules?

When a pair of codes or combination of codes is performed, the CCI edit rules programmed into your carrier’s computers check to see whether this combination is allowed by the rule set, if it is an actively enforced rule, the administrative reason for the code conflict and whether a modifier may be used to override the rule.

For example, if I wanted to perform fundus photography (92250) and threshold visual fields (92083) together on the same date of service, the rule set indicates that these two codes can be performed on the same date without any complication or issue as long as medical necessity was properly established in the medical record for both.

However, if I want to add OCT of the retina (92134) at the same session, I may have some issues. Visual fields and OCT are allowed, but the performance of fundus photography and OCT on the same day is not allowed because they are considered to be “mutually exclusive procedures.”

This means it is generally not reasonable for them to be performed on the same date of service. However, a modifier can be used to override this should the medical necessity dictate it.

Keep in mind that medical necessity means exactly that — not just because you want to or it is more convenient for the patient.

If medical necessity is established, then the guidelines specifically state that modifier -59 is allowed and should be appended to the fundus photography code (92250-59).

Modifier -59 is defined: “Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances.”

The definition of modifier -59 is very specific and should not be taken lightly, as it is an often misused/overused modifier that can raise scrutiny on the part of an insurer and the Office of Inspector General (OIG).

Modifier -59 is generally used as a modifier of last resort, when no other modifier fits the situation at hand.

Not to be ignored

The CCI edits are important rules that we need to be aware of when delivering our clinical care.

Don’t ignore them or take them casually — they are important and could trigger an audit should you not follow them.

Great tools, such as ReimbursementPlus.com, can provide real-time information about specific code combinations and conflicts. OM

DR. RUMPAKIS IS FOUNDER, PRESIDENT AND CEO OF PRACTICE RESOURCE MANAGEMENT, INC., A CONSULTING, APPRAISAL AND MANAGEMENT FIRM FOR HEALTHCARE PROFESSIONALS. E-MAIL HIM AT JOHN@PRMI.COM, OR SEND COMMENTS TO OPTOMETRICMANAGEMENT@GMAIL.COM.