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Medical Coding News Archives

CMS Updates NCCI Manual for 2016

February 15, 2016:

Changes to the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services were effective January 1, 2016. The manual details coding principles that drive its claim edits.

Modifier 59: Modifier 59 (Distinct procedural service) distinguishes those procedures or services (with the exception of E/M services) that are not typically reported together, but may be appropriate under specific circumstances. The use of modifier 59 must be corroborated by medical documentation that verifies a different session, different procedure or surgery, different site or organ system, separate incision or excision, distinct lesion, or separate injury (or area of injury in the case of extensive injuries) not typically encountered or performed on the same day by the same individual.

The manual clarifies the use of modifier 59 as it relates to time, such as per 15 minutes or per hour. If two separate and distinct timed services are provided in separate and distinct time blocks, modifier 59 may be used to identify the services whether they are sequential to one another or split. When the two services are split, the time block for one service may be followed by a time block for the second service, followed by another time block for the first service. All Medicare rules for reporting timed services apply.

For example, the total time is calculated for all related timed services performed. The number of reportable units of service is based on the total time, with the units of service allocated between the HCPCS/CPT® codes for the individual services performed. The physician may not perform multiple services, each for the minimal reportable time, and report each of these as separate units of service. For instance, a physician or therapist performs eight minutes of neuromuscular reeducation (CPT code 97112) and eight minutes of therapeutic exercises (CPT code 97110). Since the physician or therapist performed 16 minutes of related timed services, only one unit of service may be reported for one, not each, of these codes.

Radiologic guidance: The following paragraph was added throughout the manual: “If the code descriptor for a HCPCS/CPT code, CPT Manual instruction for a code, or CMS instruction for a code indicates that the procedure includes radiologic guidance, a physician should not separately report a HCPCS/CPT code for radiologic guidance including, but not limited to, fluoroscopy, ultrasound, computed tomography, or magnetic resonance imaging codes. If the physician performs an additional procedure on the same date of service for which a radiologic guidance or imaging code may be separately reported, the radiologic guidance or imaging code appropriate for that additional procedure may be reported separately with an NCCI-associated modifier if appropriate.”

Colporrhaphy: The manual adds instructions for reporting three colporrhaphy codes: 57240 (anterior colporrhaphy), 57250 (posterior colporrhaphy), and 57260 (combined anterior and posterior colporrhaphy). When additional dissection to repair a rectocele or urethrocele is performed along with a vaginal hysterectomy, the coder can report both the hysterectomy code and CPT code 57240, 57250, and 57260, along with the appropriate modifier.

Instructions clarify that fixating the vagina to surrounding tissues during a vaginal hysterectomy is considered part of the hysterectomy. Reporting CPT code 57282 (extraperitoneal vaginal colpopexy) or 57283 (intraperitoneal vaginal colpopexy) to describe this routine fixation is incorrect. These two codes may be reported, along with the appropriate modifier, only when the physician performs a more extensive colpopexy.

Cardiovascular care:

  • Only a complete right heart catheterization performed during an endomyocardial biopsy may be reported when it is medically necessary and distinct from the biopsy. If the catheterization is abbreviated, use code 93799 for unlisted cardiovascular procedures.
  • The service described by code 93355 (Transesophageal echocardiograpy for guidance for transcatheter intracardiac or great vessel(s) structural intervention(s)) is considered part of the anesthesia service and therefore should not be reported separately.
  • A few services are noted as being integral to the insertion of a pacemaker or defibrillator electrode or device and therefore not separately reportable: 93600 (Bundle of His recording), 93602 (Intra-atrial recording), 93603 (Right ventricular recording), 93610 (Intra-atrial pacing), and 93612 (Intraventricular pacing). However, the coder may report (along with an NCCI-associated modifier) a medically reasonable limited diagnostic electrophysiology test that precedes the insertion or replacement to determine whether the procedure is necessary.

Respiratory care: Practitioner ventilation management (94002–94005, 94660, 94662) and critical care (99291–99292, 99466–99486) include respiratory flow volume loop (94375), breathing response to carbon dioxide (94400), and breathing response to hypoxia (94450) testing, if performed.

Hyperbaric oxygen therapy: Physician attendance and supervision of hyperbaric oxygen therapy (code 99183) includes related evaluation and management (E/M) services. Such integral services might include:

  • Updating the history and physical
  • Examining the patient
  • Reviewing lab results and vital signs for pulmonary function, blood pressure, and blood sugar levels
  • Clearing the patient for the procedure
  • Monitoring positioning or helping the patient get in position
  • Evaluating and treating the patient for barotrauma and other complications
  • Prescribing medications

However, if a physician performs an unrelated, significant, and separately identifiable E/M service on the same date of service as the hyperbaric oxygen therapy, the physician may report those E/M services and append modifier 25.

Fracture treatment: Several manual revisions relate to fracture care:

  • Only one CPT code for closed dislocation or fracture treatment without manipulation is reported when the physician treats and stabilizes multiple dislocations or fractures with a single cast, strapping, or splint. The same principle applies for any combination of closed dislocations or closed fractures treated without manipulation in addition to at least one closed dislocation or fracture requiring manipulation: Only one CPT code for closed treatment with manipulation is reported. If no cast, strapping, or splint is required, report only one CPT code for closed dislocation or fracture treatment for the anatomic area that would have been treated by a single cast, strap, or splint.
  • Do not report a separate CPT code for closed dislocation or fracture treatment without manipulation if a cast, strap, or splint used as part of open or percutaneous treatment of a dislocation or fracture also treats a closed dislocation or fracture not requiring manipulation.
  • Do not report CPT code 20650 (Insertion of wire or pin with application of skeletal traction, including removal [separate procedure]) when skeletal traction is not used. Also, “separate procedure” means that this code should not be reported with a fracture treatment or other repair code for the same anatomic region.
  • The unit of service for CPT codes 21248 and 21249 (partial or complete reconstruction of the mandible or maxilla with endosteal implant) is based on the reconstruction, not the implant.
  • Only one unit of service is reported for closed treatment without manipulation of fractures of multiple similar bones, whether or not a cast, splint, or strap is applied. As an example, the manual describes a cast that is applied without manipulation to fractures of multiple metatarsals of the same foot—only one unit for code 28470 would be reported.
  • The same holds true for multiple carpal, tarsal, or metatarsal bones in one extremity. For example, just one unit of service for code 26600 would be reported for closed treatment without manipulation of multiple fractured metacarpal bones in one hand.
  • Although debridement of tissue in the surgical field of another musculoskeletal procedure is not reported separately, debridement of tissue at an open fracture or dislocation may be reported separately with codes 11010 through 11012.

Specimen staining during Mohs surgery: The unit of service for immunohistochemistry or immunocytochemistry codes 88341 and 88342 relates to the number of distinct stains used on specimens, not the number of specimen blocks. During Mohs surgery, the surgeon divides a tumor specimen into blocks. These blocks initially are stained with one antibody immunohistochemistry stain, which is reported with one unit of code 88342. If the surgeon also stains blocks from that specimen with a different single antibody stain, the coder reports one unit of code 88341.

CPT © 2015 American Medical Association. All rights reserved.

CPT is a registered trademark of the American Medical Association.


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