CCI Edits Affect Pulmonology Coding- Published on Sat, Apr 01, 2000
Unbundlingbilling separately for two or more procedures that CPT 2000 combines in one comprehensive code-is a major compliance problem. But many physicians dont understand this concept, which can lead to claim denials. By reviewing the basic ideas behind bundling, such as mutually exclusive, component and comprehensive codes, physicians can avoid such problems.
By far the largest source of bundling combinations, or edits, is Medicares national Correct Coding Initiative (CCI), which has developed coding policies and more than 120,000 edits for reimbursement compliance to better control improper coding.
Although the CCI has been in place since Jan. 1, 1996, many physicians still do not understand its impact on how they bill procedures. This has serious compliance consequences because Medicare auditors may construe separate billing for bundled procedures as fraud.
Component and Comprehensive Codes
Approximately 11,000, or just less than 10 percent, of the CCIs 120,000 edits are categorized as mutually exclusiveeach code covers one procedure that may not be billed at the same time as others in the group. The other 90 percent may be categorized roughly as bundlescomprehensive codes that include more than one component. Physicians may not bill the component codes if they also bill the code for the comprehensive procedure.
Effective April 1, 2000, CCI, Version 6.1, was implemented to reflect correct coding edits made by the Health Care Financing Administration (HCFA). This version of the CCI contains the following edits:
The comprehensive/component edit of CPT code 94621 (pulmonary stress testing; complex [including measurements of CO2 production, O2 uptake, and electrocardiographic recordings]), which includes 94010 (spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) and 94200 (maximum breathing capacity, maximal voluntary ventilation).
HCFA explains this edit by saying that complex pulmonary stress testing (94621) includes spirometry (94010) and maximum breathing capacity (94200) as a standard of medical and surgical practice. The agency states that complex pulmonary stress testing (94621) is a more extensive procedure than simple pulmonary stress testing (94620). The CPT description for 94620 specifically indicates pre- and post-spirometry as an integral part of the procedure code. Maximum breathing capacity (94200) also has been identified in previous CCI versions as a standard of medical and surgical practice for simple pulmonary stress testing (94620).
Editors note: If either of the two component procedures described in these code-pair edits is performed separately from the comprehensive procedure (i.e., at separate sessions or patient encounters) both the comprehensive and component codes may be reported by appending modifier -59(distinct procedural service)to the component code.
A correction for CPT codes 31628 and 31629. This change will be retroactive to Oct. 1, 1998. (In 1998, use of these codes frequently resulted in [...]