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Medical Coding News Archives

CCI April Update and Modifier 59

March 24, 2009:

The Centers for Medicare and Medicaid Services has released version 15.1 of the correct coding initiative (CCI) edits. This latest version, effective April 1, includes all previous versions and updates from January 1, 1996, to the present.

The edits are organized into two tables: Column 1/Column 2 Correct Coding Edits and Mutually Exclusive Code (MEC) Edits. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual.

The National Correct Coding Initiative (CCI) was developed to promote national correct coding methodologies and to manage improper coding that can lead to inappropriate payment of Part B claims. The purpose of the edits is to prevent improper payment when incorrect code combinations are reported. However, if an edit permits the use of NCCI-associated modifiers, the two procedure codes may be reported together when the procedures are performed at different anatomic sites or different patient encounters.

Carrier processing systems use these modifiers to allow payment of both codes of an edit. One such modifier is 59, an important and often incorrectly used modifier that indicates when two or more procedures are performed at different anatomic locations or at different patient encounters. This modifier should be appended only when no other modifier more appropriately describes the circumstances of the two or more procedure codes being reported.

Keep in mind that modifiers should not be used to simply bypass the CCI edits. Documentation within the medical record must satisfy the criteria required by any NICCI-associated modifier used.

One misuse of modifier 59 involves its definition’s specification that the modifier describes a “different procedure or surgery.” For procedures to qualify for the modifier, they must also have been performed on different anatomical sites or at different encounters. It’s not enough that they were simply different procedures—code descriptors of the codes in a code pair edit usually already indicate different procedures or surgeries. A different diagnosis is not required when modifier 59 is appended to a procedure code and, likewise, different diagnoses do not constitute the use of this modifier either. A separate site does not include treatment of contiguous structures of the same organ according to NCCI.

For more information on CCI, including the current CCI and MEC edits, visit http://www.cms.hhs.gov/NationalCorrectCodInitEd on the CMS website.

Karen M. Prescott, CMM, CPC, CPC-I, CCS-P, PCS
Clinical/Technical Editor


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