Policy No: 105
Originally Created: 11/01/2008
Section: Administrative
Last Reviewed: 10/01/2023
Last Revised: 10/01/2023
Approved: 10/12/2023
Effective Date: 11/01/2023
Policy Applies To: Group and Individual & Medicare Advantage
This policy applies as follows:
Our health plan's Correct Code Editor (CCE) code pairs, ClaimsXten™ Unbundled code pairs, practitioner NCCI Procedure-To-Procedure (PTP) edits, and MultiPlan Secondary Editor edits are applied to physicians, ASCs, and other providers.
Our health plan's Correct Code Editor (CCE) code pairs apply only to lab and radiology services when billed by outpatient facilities.
Outpatient Code Editor (OCE) Outpatient PTP edits are applied to outpatient hospitals.
National Correct Coding Initiative (NCCI)
The Centers for Medicare & Medicaid Services (CMS) developed these edits to promote consistent and correct coding and reduce inappropriate payment. These coding edits are developed based on procedures referenced in the American Medical Association's (AMA) Current Procedural Terminology (CPT®) Manual and the Healthcare Common Procedure Coding System (HCPCS) Manual as well as analysis of standard medical and surgical practice, input from speciality societies, other national healthcare organizations, Medicare contractor medical directors and staff, providers, consultants, etc. NCCI refers to these code pairs as Procedure-to Procedure (PTP) edits.
Correct Code Editor (CCE) Code Pairs
Developed by our health plan to support the Medicare and CPT written rules not included in the NCCI code pairs. The CCE code pairs are used to supplement the NCCI code pairs.
ClaimsXten Unbundled Code Pairs
Developed by Lyric to supplement the NCCI code pairs.
Unbundling
The use of multiple CPT/HCPCS codes to report a procedure when a single code adequately describes the service or supply.
Incidental
Services that are necessary and integral to accomplish a larger procedure and should not be reported separately.
MultiPlan Secondary Editor Edits
Developed by Multiplan for editing according to a variety of resources including but not limited to Reimbursement Policy, CMS, and AMA.
Mutually exclusive
Services that cannot reasonably be performed at the same anatomic site or during the same patient encounter.
CMS NCCI Modifier indicator of "0"
Indicates that NCCI-associated modifiers cannot be used to bypass the edit.
CMS NCCI Modifier indicator of "1"
Indicates that NCCI-associated modifiers may be used to bypass an edit under appropriate circumstances.
Add-on codes
Codes that are always performed in addition to a the primary service or procedure and must never be reported as a stand-alone code.
CMS Status Indicator "T" codes
Codes that are only paid if there are no other services payable under the physician fee schedule (PFS) billed on the same date by the same provider. If any other services payable under the PFS are billed on the same date by the same provider, these services are bundled into the service(s) for which payment is made.
Our health plan uses the NCCI code pairs, our CCE code pairs, ClaimsXten Unbundled code pairs, and MultiPlan Secondary Editor edits to identify and deny unbundled, mutually exclusive, or incidental services.
Procedures should be reported with the CPT or HCPCS code that describes the services performed to the greatest specificity possible and only if all services described by that code are performed. Unbundling occurs when multiple codes are used to report a procedure covered by a single comprehensive CPT or HCPCS code.
Examples of unbundling, mutually exclusive or incidental services include:
- Fragmenting one service into component parts and coding each component as if it were a separate service. For example, the correct comprehensive CPT code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239. Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43605 for biopsy of the stomach is inappropriate.
- Breaking out bilateral procedures when one code is appropriate. For example:
- Bilateral mammography is correctly coded using CPT code 77066. Bilateral mammography should not be reported using CPT code 77065 – unilateral with two units of service or 77065-RT and 77065-LT.
- Bilateral sinus endoscopy with maxillary antrostomy is correctly coded using CPT code 31256-50. Bilateral sinus endoscopy with maxillary antrostomy should not be reported using CPT code 31256 with two units of service or 31256-RT and 31256-LT. It is not appropriate to report modifiers 59, XP, XS, XU for procedures performed on the same/ipsilateral sinus. This does not apply to ASCs as they have separate bilateral coding guidelines.
- Reporting separately, services that are integral to a more comprehensive procedure. For example, surgical access is integral to a surgical procedure therefore CPT code 49000 for exploratory laparotomy should not be reported with other open abdominal procedure such as 44150 – total abdominal colectomy. Another example, pain control when provided by the surgeon, is included in the global surgical package and is not separately reimbursed. Placement of the pain pump catheter is also considered included in the allowance for the primary procedure. For example, insertion of a non-biodegradable drug delivery implant catheter is an integral part of trans catheter therapy by infusion. CPT codes 11981 and 61650 are often incorrectly billed for placement of a pain pump catheter for postoperative pain control at the time of the primary procedure.
- Procedures or services where the Centers for Medicare and Medicaid Services (CMS) written policy states to deny when billed with a more comprehensive or related procedure.
- Lysis of adhesions that are not extensive and don't require significant additional time when performed with another surgical procedure.
- Exploratory and "scout" procedures (e.g., exploratory laparotomy) followed by a definitive procedure.
- "Separate Procedure" codes as defined by CPT when performed with a more comprehensive procedure.
- Unlisted codes when used to represent an 'incident to' service:
- CPT code 29999 used to report Iliopsoas recession surgery AND billed with hip arthroscopy procedure codes 29861-29863 and 29914-29916.
CMS Status Indicator "T" codes.
The NCCI code pairs, our CCE code pairs and ClaimsXten Unbundled code pairs define when two codes may not be reported together except under special circumstances. When these special circumstances are met, the proper modifier should be appended to the appropriate code to describe the circumstances. Bundling edits are applied in ClaimsXten. More information about ClaimsXten editing can be found in the ClaimsXten Editing section of our Coding Toolkit.
NCCI-associated modifiers, as defined by CMS, are accepted by our health plan as indication of special circumstances which may allow codes to be reported together. For the NCCI code pairs, our health plan follows the CMS modifier indicator rules for determining whether a special circumstance could be indicated by a modifier.
However, our health plan has determined through review of the medical records that bypass modifiers are frequently used inappropriately on certain code pairs. These code pairs will continue to trigger a NCCI or CCE denial even when a bypass is appended. Lists of those code pairs associated with each of these modifiers is available on our health plan's provider website.
It is important that modifiers only be used when appropriate. For the purposes of NCCI and CCE, these circumstances relate to separate patient encounters, separate anatomic sites, or separate specimens. The submission of a claim with a modifier appended to a code indicates that documentation is available in the patient's records for review upon request that will support the use of the modifier.
The following are NCCI-associated modifiers:
24 - Unrelated E&M by Same Physician during Postoperative Period
25 - Separate E&M on Same Day
27 - Multiple outpatient hospital E&M encounters on the same day
57 - Decision for Surgery
58 - Staged Procedure
59 - Distinct Procedure
78 - Return to OR
79 - Unrelated Proc in Post-op
91 - Repeat Lab
E1-E4 - Eyelids
F1-F9 - Digits, Fingers
FA - Digits, Fingers
LC - Left Circumflex Coronary Artery
LD - Left Anterior Descending Coronary Artery
LM - Left Main Coronary Artery
LT - Left
RC - Right Coronary Artery
RI - Ramus Intermedius Coronary Artery
RT - Right
T1-T9 - Digits, Toes
TA - Digits, Toes
XE - Separate Encounter
XP - Separate Practitioner
XS - Separate Structure
XU - Unusual Non-Overlapping Service
Our health plan will deny an add-on code as a CCE code pair denial when its primary code is denied as part of a NCCI or CCE code pair. When the primary code is submitted with modifiers 59, XE, XP, XS or XU to indicate a separately identifiable procedure, the add-on code must also be submitted with modifiers 59, XE, XP, XS or XU to avoid the CCE code pair denial.
NCCI Policy Manual for Medicare Services, current version Chapter 1.
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