During the past seven years the Correct Coding Initiative (CCI)—Medicare's national editing software system that bundles various procedural code combinations—has evolved into a complicated electronic claims processing system directly affecting billing and reimbursement and requiring careful monitoring by radiology and radiation oncology practices.
CCI edits emerged due to a 1995 Government Accounting Office report that hundreds of millions of all Medicare dollars spent resulted from fraud, abuse, or waste. To solve this problem, Congress mandated that software be developed to detect unbundling—the billing of multiple procedure codes to describe a service when one code would be more appropriate. In January 1996 the Health Care Financing Administration (now known as the Centers for Medicare and Medicaid Services), the agency responsible for overseeing the Medicare program, implemented its first round of edits to curb coding abuse.
The CCI edits apply only to services that are performed on the same day for the same patient and billed by the same physician (i.e., on the same claim form). This means that studies performed by different physicians on the same patient on the same day or different studies for the same patient on different days are not subject to CCI edits. CCI edits apply to all physicians who bill for services on the Medicare claims processing form typically used by radiology offices (i.e., CMS-1500) as well as to outpatient hospital claims as part of the Ambulatory Payment Classification (APC) system. When Medicare is billed for coding combinations that are bundled in CCI, generally Medicare will only reimburse for one code: the one with the lowest value. Aside from Medicare, other third-party payers may utilize CCI or another version of coding edits. Therefore, understanding CCI and knowing which codes may or may not be billed together has direct financial and fraud-and-abuse implications for radiology and radiation oncology practices.
Initially, CCI edits consisted of two types of code pair combinations: "Comprehensive/Component" code pair edits and "Mutually Exclusive" code pair edits. The "Comprehensive/Component" edits identify coding combinations in which a procedure code is a "component" or integral part of a more "comprehensive" procedure code. For example, CPT® code 70551 (MRI brain, without contrast) is a component of CPT® code 70553 (MRI brain, without contrast followed by with contrast).
The "Mutually Exclusive" edits identify coding combinations consisting of two procedures that cannot reasonably be performed together based on the CPT code definition, anatomic considerations, or standard of medical practice. For example, CPT® code 78645 (CFS flow imaging) is mutually exclusive from CPT® code 78650 (CFS leak detection and localization). Clinically, if a patient undergoes one of these procedures, it is highly unlikely that the other would also be performed on the same day.
Revision to the CCI Edits Table
The Centers for Medicare and Medicaid Services retitled the Comprehensive/Component edits code table to "Column 1/Column 2" edits in August 2003 in an effort to clarify that the CCI edits are no longer limited to the definition of comprehensive/component services. Radiology and radiation oncology practices have been confused by the edits being implemented by CMS, since many of these code pair edits have no Comprehensive/Component code relationship. According to CMS, the retitling of the CCI edits table better reflects the nature of the edits included in this table. For example, some edits listed in this table are based on policy such as CPT® coding guidelines. Two examples:
Column 1 CPT® code 76490 (ultrasound guidance, tissue ablation) and column 2 CPT® code 76986 (ultrasound guidance, intra-operative) are paired because the CPT manual states "Do not report 76490 in addition to code 76986." The logic behind this edit is that if a patient underwent a procedure using intra-operative ultrasound, it is unlikely that the patient would also receive another ultrasound-guided service on the same day or during the same session.
Column 1 CPT® code 49520 (recurrent inguinal hernia repair) and column 2 CPT® code 49568 (implantation of mesh/prosthesis for hernia repair) are paired, because the CPT manual notes that code 49568 is listed separately in addition to the code for incisional or ventral hernia repair. Since procedure code 49520 is an inguinal hernia repair, code 49568 would not apply to code 49520.
In an August 13, 2003 letter to the AMA, CMS asked that the AMA notify the various medical specialty societies of this retitling change, which CMS plans to phase in over the next eight months in its manuals, on its Web sites and in other products that refer to these CCI edits.
CCI and the Use of Modifiers
Even though a code combination may be listed as a CCI edit, CMS does allow for billing and payment of both codes identified in a code pair edit under certain circumstances and when submitted with a modifier. CCI identifies each coding combination edit with a modifier indicator to identify which procedure code combinations may be billed together with the use of a modifier. CMS employs three types of modifier indicators: "0", "1" and "9."
A modifier indicator of "0" marked on a code edit signifies that these codes should not be billed together and that only one will be paid regardless of any circumstances for both services. For example, CPT® code 78461 (myocardial perfusion imaging, multiple studies) and CPT® code 78460 (myocardial perfusion imaging, single study) is an example of a Column 1/Column 2 CCI edit that has a "0" modifier indicator. The "single study" is included in the "multiple studies" service.
Modifier "1" indicator recognizes that there are clinically valid instances when the "component" or "column 2" procedure would be performed in addition to the "comprehensive" or "column 1" procedure; therefore, it is appropriate to bill both codes as long as a modifier is attached to one of the codes to designate a separate and distinct study, and medical necessity is documented in the report. CPT® code 75790 (angiography) and CPT® code 76942 (ultrasound guidance) are examples of a CCI edit that has a "1" modifier indicator. There may be times when it is necessary to perform both services on a given day. When this code combination is submitted to Medicare a modifier must be added to one of the codes.
Note: The modifier "9" indicator represents a "non-applicable" edit, which typically means that the Column 1/Column 2 edit and/or the Mutually Exclusive edit have been deleted.
In those instances where it is acceptable to use a modifier, the CPT® manual has a listing of modifiers from which to select. These modifiers are meant to provide additional information to the payers on the procedures/services provided. The most commonly used modifier, –59, is described by CMS as a "distinct procedural service." Per CPT® manual instructions, "this may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or are of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician."
Although modifier –59 is used to designate a separate and distinct procedure, CPT coding guidelines instruct the user to use a more appropriate modifier if available (e.g., RT, LT, –51). However, many Medicare carriers are not consistent in recognizing other types of modifiers in their electronic claims systems, therefore, it is typically recommended that radiology and radiation oncology practices check with their local Medicare carrier and other third party payers for their specific guidelines on modifier usage. As a result of the lack of recognition of modifiers and the change in definition of the CCI edits, the utilization of the –59 modifier has increased to a much higher level than ever intended by CMS.
CCI Edit Review Process
Over the years the CCI process has been refined to allow specialty societies the opportunity to review and comment on the CCI edits to AdminaStar Federal (the CMS contractor responsible for the development and implementation of CCI edits) prior to their implementation. The volume of edits that are developed and changed annually has led to the need for continuous review and comment by the medical specialty societies, as well as continuous educational efforts to communicate to radiology and radiation oncology practices which code combinations are allowed and not allowed by Medicare (e.g. see the CCI Update section of this bi-monthly newsletter). Medical specialty societies receive quarterly proposed CCI edits, as well as biannual proposed CCI edits identified in the Medicare claims data. In addition, there are many other individual edit issues that are handled by letters and/or conference calls with AdminaStar Federal.
The ACR reviews and comments on a high volume of edit issues related to radiology and radiation oncology, amounting to over 10,000 edits a year. The ACR and other specialty societies provide feedback to CMS regarding which proposed edits they deem inappropriate. As a result, numerous edits have been deleted or allowed with a modifier indicator "1." However, CMS continues to keep some contested edits; therefore, radiology and radiation oncology practices are encouraged to send to the ACR Economics and Health Policy Department for review any claim denials caused by the CCI that appear to be inappropriate.
For copies of ACR comment letters to AdminaStar and CMS on various proposed CCI edits please go to the ACR Web site.
CCI Edits Now Available on CMS Web Site
CMS recently made the CCI edits available on its Web site at no cost to the user in an attempt to better communicate with the physician community. CCI edits were previously available only through paid subscriptions by selected vendors licensed to handle the information. These edits are accessible and posted in a spreadsheet format, which can be accessed here. They are listed in two separate tables (column 1/column 2 and mutually exclusive) by series of codes (e.g., 70000-79999), which allows users to sort by procedure code and effective date. However, the file size may be too large to download onto individual computers; therefore, it may be easier to utilize online. In addition, the CCI edits posted on the CMS Web site are not listed by sub-specialty, and it may be difficult for a new user to understand historical edits such as the meaning of deletion dates and effective dates. For example, an edit may be listed as "deleted" in the Mutually Exclusive table; however, this might simply mean that the edit was moved into the Column 1/Column 2 table and could still be applicable. Vendor subscriptions may still be advantageous—especially for new users—because of the interpretative considerations when reviewing the CCI online.
For more details on the development of the edit system, you may contact the ACR at firstname.lastname@example.org. You may also refer to the CMS Web site page, which includes links to documents with information on: the CCI Policy Manual for Part B, the Medicare Carriers Manual pertaining to these edits, and CCI Question and Answer page.