A hospitalist who scrutinizes claims might notice a payment denial related to “unbundling” issues. Line-item rejections might state the service is “mutually exclusive,” “incidental to another procedure,” or “payment was received as part of another service/procedure.” Unbundling refers to the practice of reporting each component of a service or procedure instead of reporting the single, comprehensive code. Two types of practices lead to unbundling: unintentional reporting resulting from a basic misunderstanding of correct coding, and intentional reporting to improperly maximize payment of otherwise bundled Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes.1
The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) for implementation and application to physician claims (e.g., Medicare Part B) with dates of service on or after Jan. 1, 1996. The rationale for these edits is a culmination of:
- Coding standards identified in the American Medical Association’s (AMA) CPT manual;
- National and local coverage determinations developed by CMS and local Medicare contractors;
- Coding standards set forth by national medical organizations and specialty societies;
- Appropriate standards of medical and surgical care; and
- Current coding practices identified through claim analysis, pre- and post-payment documentation reviews, and other forms of payor-initiated audit.
The initial NCCI goal was to promote correct coding methodologies and to control improper coding, which led to inappropriate payment in Part B claims.2 It later expanded to include corresponding NCCI edits in the outpatient code editor (OCE) for both outpatient hospital providers and therapy providers. Therapy providers encompass skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy (OPTs) and speech-language pathology providers, and home health agencies (HHAs).
The NCCI recognizes two edit types: Column One/Column Two Correct Coding edits and Mutually Exclusive edits. Each of these edit categories lists code pairs that should not be reported together on the same date by either a single physician or physicians of the same specialty within a provider group.
When applying Column One/Column Two editing logic to physician claims, the Column One code represents the more comprehensive code of the pair being reported. The Column Two code (the component service that is bundled into the comprehensive service) will be denied. This is not to say a code that appears in Column Two of the NCCI cannot be paid when reported by itself on any given date. The denial occurs only when the component service is reported on the same date as the more comprehensive service.
For example, CPT code 36556 (insertion of nontunneled centrally inserted central venous catheter, age 5 years or older) is considered comprehensive to codes 36000 (introduction of needle or intracatheter, vein) and 36410 (venipuncture, age 3 years or older, necessitating physician’s skill [separate procedure], for diagnostic or therapeutic purposes). These code combinations should not be reported together on the same date when performed as part of the same procedure by the same physician or physicians of the same practice group. If this occurs, the payor will reimburse the initial service and deny the subsequent service. As a result, the first code received by the payor, on the same or separate claims, is reimbursed, even if that code represents the lesser of the two services.
Mutually Exclusive edits occur with less frequency than Column One/Column Two edits. Mutually Exclusive edits prevent reporting of two services or procedures that are highly unlikely to be performed together on the same patient, at the same session or encounter, by the same physician or physicians of the same specialty in a provider group. For example, CPT code 36556 (insertion of nontunneled centrally inserted central venous catheter, age 5 years or older) would not be reported on the same day as 36555 (insertion of nontunneled centrally inserted central venous catheter, younger than 5 years of age).
CMS publishes the National Correct Coding Initiative Coding Policy Manual for Medicare Services (www.cms.hhs.gov/NationalCorrectCodInitEd) and encourages local Medicare contractors and fiscal intermediaries to use it as a reference for claims-processing edits. The manual is updated annually, and the NCCI edits are updated quarterly. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty of SHM’s inpatient coding course.
- National correct coding initiative edits. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/NationalCorrectCodInitEd. Accessed March 10, 2009.
- Medicare claims processing manual. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed March 10, 2009.
- Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press, 2008;477-481.
- Modifier 59 article. Centers for Medicare and Medicaid Services Web site. Available at: www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf. Accessed March 10, 2009.
- French K. Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians. 2008;283-287.