Just as it's important that your coders know when a combination of codes warrants a bundling edit, it's crucial that they know when it's OK to bypass an edit.

Exceptions to the rule
Certain code combinations may warrant an exception based on clinical documentation. Many combinations of codes reflect a bundling edit, but a correct coding modifier (CCM) indicator will let the coder know whether a modifier may be applied to bypass the edits in cases, for example, when surgeons perform separate and distinct procedures.

A CCM indicator of 1 indicates that you may bypass an edit with a modifier, thus letting you report both services. A CCM indicator of 0 indicates that no separate payment will be made regardless of the modifier you apply. A correct coding modifier indicator of 9 indicates that the bundling edit is no longer applicable.

When it comes to Medicare edits, coders have 2 tendencies. They either err on the side of caution when reviewing the edits or they don't understand when they should append a modifier to the CPT code to indicate a separate and distinct procedure that would otherwise be considered bundled. The better the coder knows the procedure and the more she understands the rationale behind the National Correct Coding Initiative edits, the easier she'll be able to determine whether a modifier is applicable.

The NCCI was implemented to ensure consistent, correct coding across different states and jurisdictions, and to minimize improper coding that could potentially lead to inappropriate reimbursement. The NCCI identifies coding combinations that normally shouldn't be billed by the same provider for the same patient on the same day. The NCCI edits consist of pairs of HCPCS codes that are arranged into 2 tables — the Column 1/Column 2 Correct Coding Edits table and the Mutually Exclusive Edits table. A common mistake is to code with a "quick fix" mentality. By this we mean overlooking the CCM indicator. Don't code with blinders on. A tendency of NCCI edits users is to interpret the codes found in Column 2 to be bundled at all times with codes found in Column 1, thereby disregarding the CCM indicators. An understanding of the rationale behind the edits will ensure that correct coding becomes second nature.

Here are a few specialties where misinterpreting the NCCI edits can cost you facility reimbursement:

Gastroenterology. Medicare edits bundle CPT 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) into CPT 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s) or other lesion(s) by snare technique) but allow for a modifier (-59) if the biopsy of a polyp and the removal of a polyp by snare technique are 2 separate and distinct procedures performed on 2 separate and distinct lesions.
CPT 45385 = $380.23
CPT 45380-59 = $380.23/2

Pain management. Medicare edits bundle CPT 64483 (Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level) into CPT 62311 (Injection, single, epidural or subarachnoid; lumbar, sacral [caudal]), considering 64483 as mutually exclusive. The correct coding modifier indicator (1) allows for a modifier (-59) to be appended to CPT 64483 when performed at a different level than the injection reported by CPT 62311. The physician's documentation should detail the specific levels and regions he's entering and injecting.
CPT 62311 = $295.98
CPT 64483-59 = $295.98/2

Orthopedics. Medicare edits bundle CPT 29823 (Arthroscopy, shoulder extensive debridement) into CPT 29824 (Arthroscopy, shoulder, surgical; distal claviculectomy) at this time but allow for a modifier if the debridement is performed separate and distinct from the distal claviculectomy. A coder unfamiliar with Medicare edits and their conventions might report only CPT 29824 since CPT 29823 is listed in the Medicare edits as an integral component despite operative documentation to the contrary. On the flip side, a coder that understood the detailed operative description and knew when to apply the -59 modifier would report both CPT 29824 and 29823-59 and capture additional reimbursement. An important note: Documentation must describe extensive debridement in significant areas/sites separate and distinct from the area/site of the distal claviculectomy in order to report both codes.
CPT 29823-59 = $1,588.70
CPT 29824 = $1,070.42/2

Orthopedics. Medicare edits bundle CPT 29807 (Arthroscopy, shoulder, surgical; repair of SLAP lesion) into CPT 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy) at this time, but allow for a modifier (-59) if the surgeon performs a specific arthroscopic SLAP repair separate and distinct from the arthroscopic capsulorrhaphy and the capsulorrhaphy is unrelated to the SLAP repair. Use caution when considering the application of a modifier. Remember the terms "separate" and "distinct."
CPT 29806 = $1588.70
CPT 29807-59 = $1,588.70/2

Medical necessity
While we may have navigated through our decision-making processes, let's not forget that medical necessity requirements will play a role in reimbursement. Local coverage determination policies provide documentation and medical necessity essentials for specific procedures. Your Medicare administrative contractor/fiscal intermediary may offer LCD policies that provide more specific coding, reporting and medical necessity directives for more common procedures. When you combine a working knowledge of the NCCI edits and CPT coding guidelines with detailed clinical documentation/medical recordkeeping, coders should be confident with final code selections. It will be these very resources and directives that will serve as backup should the coder need to show credible documentation supporting the decision-making process.