November 27, 2007 Bottom Line

Bottom Line: Billing Procedures for Code Pairs

What's Allowed and What's Not

The Centers for Medicare and Medicaid Services (CMS), using an automated edit system, controls specific Current Procedural Terminology (CPT) code pairs that can be billed for one patient on the same day on Medicare claims. The National Correct Coding Initiative (NCCI or, more commonly, CCI), in place since January 1, 1996, is updated quarterly to identify code pairings that may not be billed for an individual patient on the same day.

Code pairs are listed if they are "mutually exclusive" of each other; if they are deemed components of more comprehensive services; or because it is "otherwise inappropriate" to provide the services on the same day.

Q: Do the CCI rules apply only to Medicare-covered services?

No. Some private health plans and Medicaid programs have adopted this Medicare edit system. Providers can ask payer organizations if they use this system.

Q: Are there certain Medicare provider settings for which the edits do not apply?

No. Prior to 2006, enforcement applied only to private-practice settings, but facilities are now included as well.

Q: A private health plan has denied the speech-language evaluation I administered because it was performed on the same day that I rendered a swallowing evaluation. The payer does not utilize the CCI edits. What recourse do I have?

In your appeal, you should include the CCI edit table (see the complete table or an abridged form), indicating that Medicare places no restrictions on CPT 92506 and 92610 performed on the same day. Although a private payer is not bound by the CCI rules, the payer should understand that Medicare has developed the CCI system in a careful and comprehensive manner.

Q: Can an exception be requested for a specific code pair?

Yes. Certain code pairs include an indicator that allows the -59 modifier to be attached to the second code of the pair. The modifier denotes that the two procedures are distinct; this assertion must be supported in the medical record. Examples of pairs that allow the -59 modifier are:

  • Audiology
    92585 (evoked potentials, comprehensive)/92586 (evoked potentials, limited)
    92625 (tinnitus assessment)/92562 (loudness balance test)
  • Speech-Language Pathology
    92508 (SLP group treatment)/92507 (SLP treatment)
    92611 (modified barium swallow)/92610 (dysphagia evaluation)

Q: Is ASHA working to remove any code pairs?

Yes. Examples are two code pairs that couple procedures usually performed by physicians with procedures often performed by speech-language pathologists. ASHA believes it is feasible to argue for the allowance of the -59 modifier so the procedures may be performed on the same day. The pairs are:

  • 31575 (diagnostic laryngoscopy) and 31579 (videostroboscopy)—Special Interest Division 3, Voice and Voice Disorders, is working with ASHA's Health Care Economics and Advocacy Team to document physician support for allowing these procedures to be provided on the same day. Under current regulations, if a physician performs the laryngoscopy, the patient must make a separate return trip for the videostroboscopy. ASHA's plan is to request revision of the edit jointly with the American Academy of Otolaryngology–Head and Neck Surgery.
  • 92612 (fiberoptic endoscopic evaluation of swallowing) and 31575 (diagnostic laryngoscopy)—Special Interest Division 13, Swallowing and Swallowing Disorders, is using a similar strategy to request revision of the edit.

Q: If a certain code pair is not listed, is there an additional source to verify that the Medicare claim review will consider the pair appropriate?

Procedures performed outside of the listed code pairs are not subject to CCI restrictions and can be billed on the same day without a modifier. A separate review regarding the medical necessity of the procedure(s) would be unrelated to the procedure pairing.

Q: Who analyzes and approves proposed CCI edit pairs?

Correct Coding Solutions LLC (P.O. Box 907, Carmel, IN 46082-0907, fax 317-571-1745) contracts with CMS to process edits. However, all proposed additions and deletions are circulated quarterly to medical specialty societies and non-physician practitioner associations (including ASHA) for comment.

Q: Where can I find the CCI tables on ASHA's Web site?

Q: How do I access the CMS source of CCI edit pairs for all disciplines?

Go to the CCI Web site. Code pairs that allow the -59 modifier are identified by a "1" adjacent to the pair; pairs that do not accept the modifier are identified with a "0." A date next to the code pair indicates when it was deleted; all other code pairs are active.

Mark Kander, director of health care regulatory analysis, can be reached at mkander@asha.org.

cite as: Kander, M. (2007, November 27). Bottom Line: Billing Procedures for Code Pairs : What's Allowed and What's Not. The ASHA Leader.

  

Advertise With UsAdvertisement