CCI Edits Well To Keep Denials at Bay

With CCI 16.0 coming your way soon, you need to stay tuned to the latest and know how to get your claims paid and stay compliant.

If you are not aware of what correct coding initiative (CCI) edits are, how they function, and how they affect your claims, you’re risking denials, fraud charges, and lost reimbursement. Stay tuned for CCI edits and other medical coding career information.

All about CCI edits:

• Every year each quarter, CCI puts out a list of code pairs that Medicare and other private payers follow when they reimburse physician practices. The CCI edits list pairs of CPT and HCPCS codes that payers will not pay on when you bill them jointly. Medicare applies CCI edits to services you bill for the same provider, for the same beneficiary, on the same date of service.

All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2).

Remember: If you happen to bill for a hospital, keep in mind that hospital edits run one quarter behind physician CCI edits. According to Joan Gilhooly, CPC, CHCC, president of Medical Business Resources LLC in Deer Park, III, you should pay special attention to the start/stop dates in the adjacent columns since CCI edits are ‘date of service’ sensitive.

• Two edit types: The first type of edit, mutually exclusive edits pair procedures or services that the physician could not reasonably perform at the same session on the same beneficiary. The other type of edit, column 1/column 2 edits, is described “bundled” procedures.

If you bill two mutually exclusive codes for the same patient during the same session, payers toeing CCI rules will reimburse only for the lesser valued of the two procedures. On the other hand if you bill bundle (column 1/column 2) procedures for the same patient during the same session, payers will pay you only for the higher-valued among the two.

• Can you ever ignore the edits? The answer is no. In certain clinical circumstances, you can override - but not ignore - CCI edits and receive separate reimbursement for bundled codes. In order to find out if you can separately bill services your physician performed, you need to check the modifier indicator in column F of the CCI spreadsheet. While a “0” indicator means you cannot unbundle the two codes under any circumstances, an indicator of “1” means that you may use a modifier to override the edit if the clinical circumstances warrant separate reimbursement.