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Providers Not Up on CCI Edits Risk Accusations of Bundling

February 10, 2009:

The Correct Coding Initiative edits that went into effect for professional claims on January 1, 2009 (version 15.0), include thousands of changes that are already affecting claims. As bundling is frequently the reason for claim denials, it is essential for providers to keep up-to-date with the quarterly updates to CCI edits.

The CCI is a collection of edits developed by the Centers for Medicare and Medicaid Services (CMS) to ensure correct coding and thus reduce or eliminate inappropriate Medicare payments. The CCI edits identify pairs of CPT or HCPCS Level II codes that are not separately payable. The edits also check for mutually exclusive code pairs and the maximum number of services allowed for each code (i.e., unit-of-service edits.) The CCI coding policies are based on the American Medical Association’s (AMA) CPT book, national and local policies, and coding guidelines developed by national specialty societies, in addition to an analysis of standard medical practice and current coding practices. The edits are applied to services billed by the same provider for the same patient on the same date of service. Medicare claims processing systems, and many private payers, subject all claims to these edits to identify incorrect billing of medical services.

Version 15.0 of the CCI, effective on January 1, 2009, includes more than 42,000 edit additions and 38,000 deletions and revisions. The musculoskeletal subsection of CPT alone contains 8,159 additions and 7,832 deletions; the anesthesia section includes 5,594 new edits and 3,849 deletions. Many of these changes relate to the new 2009 CPT codes. For example, most of the new infusion CPT codes (96360, 96365, 96369, 96372–96374) are bundled into the physician office/outpatient evaluation and management codes (99201–99215, 99241–99245). A modifier for bypassing the edits is allowed under the proper circumstances (i.e., when the services are medically necessary and separately identifiable.)

The CCI also includes a correct coding modifier (CCM) indicator, which determines whether a modifier may be appended to allow a code pair to bypass the edit. These indicators include the following:

0 = A modifier is not allowed and will not bypass the edits.
1 = A modifier is allowed and will bypass the edits.
9 = Use of modifiers is not specified.

Most of the modifier indicator revisions in version 15.0 no longer allow certain code pairs to bypass the edits although a modifier override was allowed previously. For example, narcosynthesis for psychiatric diagnostic and therapeutic purposes (90865) is “bundled” with the psychotherapy codes (90804–90829). The Correct Coding Modifier indicator has been changed to 0, indicating a modifier is not allowed, so these code pairs may no longer bypass the edits. Modifier indicators were also changed for electroconvulsive therapy (90870) and psychoanalysis (90845), health/behavior assessments (96150–96154), and smoking/tobacco cessation counseling visits (99406–99407) so that a modifier to bypass the edit is no longer allowed. Polysomnography sleep staging (95808–95811) and needle electromyographic procedures (95860–95864) also saw modifier indicator changes in the current CCI version.  However, for these codes the modifier indicator was changed to 1 so a modifier is now allowed, under the proper circumstances, to override the edits.

Medicare implemented the CCI edits for dates of service on or after January 1, 1996, to process professional claims. Many of the CCI edits are also incorporated into the Outpatient Code Editor (OCE). OCE edits are used to process hospital outpatient prospective payment system (OPPS) claims. The CCI edits for outpatient hospital services are implemented one quarter after the CCI edits are implemented for professional claims. The latest version of edits, version 15.0, was effective January 1, 2009, for professional claims and incorporates all code changes through December 31, 2008. Version 15.0 will be applied to outpatient hospital services effective April 1, 2009.

Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS
Clinical/Technical Editor


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