Question: I understand that CMS (Center for Medicare and Medicaid Services) has added NCCI (National Correct Coding Initiatives) edits that no longer allow the billing of debridement with hundreds of surgical codes. What is the impact? How do NCCI edits affect urgent care in general?

Answer: NCCI edits define when two procedure codes may not be reported together except under special circumstances. Medicare implemented NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. Your billers should check the edits whenever two or more procedures are billed for the same patient on the same date of service. If procedures are billed incorrectly and denied, Medicare prohibits you from billing the patient for the denied services, and an ABN (Advance Beneficiary Notice) cannot be utilized.

When a claim is processed by Medicare or a Medicare contractor, the system tests every pair of procedures with the NCCI edit rules. If a pair of billed codes matches a pair of codes listed in the edits, the code listed in “Column Two” will be denied. However, an appropriate modifier can bypass the edit, providing the procedures are performed at different anatomic sites, or in the case of repeat clinical diagnostic laboratory tests.

For example, a coder should not report CPT (Current Procedural Terminology) code 64450, “Injection, anesthetic agent, other peripheral nerve or branch” with CPT code 12002, “Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm” because the NCCI edit reports that the “anesthesia service is included in surgical procedure.” However, because the modifier indicator is “1,” a modifier could be used to get past the edit, if a separate digital block was performed on a different body area and documented.

The NCCI-associated modifiers are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, LM, RC, RI, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, XE, XS, XP, XU, 24, 25, 27, 57, 58, 59, 78, 79, and 91.

The table below shows the modifier indicator definitions on if a modifier is allows for the code pair to bypass the edit:

Modifier Indicator Table
MODIFIER INDICATOR  DEFINITION
0 (Not Allowed) There are no modifiers associated with NCCI that are allowed to be used with this PTP (Procedure-to-Procedure) code pair; there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider.
1 (Allowed) The modifiers associated with NCCI are allowed with this PTP code pair when appropriate.
9 (Not Applicable) This indicator means that an NCCI edit does not apply to this PTP code pair. The edit for this PTP code pair was deleted retroactively.

 

Guidance on how to use all NCCI tools can be found at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf.

This past October, thousands of new code pairs were added to the list of bundled codes, many of which bundle debridement services into other surgical and medical procedures. The debridement codes added to the edits are:

  • 11000-11006, debridement of extensive eczematous or infected skin
  • 11042-11047, debridement of subcutaneous tissue
  • 97597-97598, debridement without excision

For example, CPT codes 10120, “Incision and removal of foreign body, subcutaneous tissues; simple” and 10121, “…complicated” are now bundled with the debridement codes shown above. If you were performing debridement in a separate body area from where the removal of the foreign body took place, your biller would need to add modifier -59 to the debridement code in order for it to pass the NCCI edit. If the modifier is not there, the procedure will be denied as being included in the service performed for CPT code 10120 or 10121.

Additional bundled code pairs involving debridement services are the cast application and strapping codes, 29000-29584. These also have a modifier indicator of “1” so that an appropriate modifier will bypass the edit when necessary.