Policy Statement
Our health plan uses the NCCI code pairs, our CCE code pairs, ClaimsXten Unbundled code pairs, Tertiary Editor Edits, Outpatient Code Editor (OCE) Outpatient PTP edits, and Claritev Secondary Editor edits to identify and deny unbundled, mutually exclusive, or incidental services.
Procedures should be reported with the CPT / HCPCS code that describes the services performed to the greatest specificity possible and only if all services described by that code are performed. Unbundling occurs when multiple codes are used to report a procedure covered by a single comprehensive CPT / HCPCS code.
Examples of unbundling / mutually exclusive / incidental services include:
- Fragmenting one service into component parts and coding each component as if it were a separate service. For example, the correct comprehensive CPT code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239. Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43605 for biopsy of the stomach is inappropriate.
- Breaking out bilateral procedures when one code is appropriate. For example:
- Bilateral mammography is correctly coded using CPT code 77066. Bilateral mammography should not be reported using CPT code 77065 – unilateral with two units of service or 77065-RT and 77065-LT.
- Bilateral sinus endoscopy with maxillary antrostomy is correctly coded using CPT code 31256-50. Bilateral sinus endoscopy with maxillary antrostomy should not be reported using CPT code 31256 with two units of service or 31256-RT and 31256-LT. It is not appropriate to report modifiers 59, XP, XS, XU for procedures performed on the same/ipsilateral sinus. This does not apply to ASCs as they have separate bilateral coding guidelines.
- Reporting separately, services that are integral to a more comprehensive procedure. For example, surgical access is integral to a surgical procedure, therefore CPT code 49000 for exploratory laparotomy should not be reported with other open abdominal procedures such as 44150 – total abdominal colectomy. Another example, pain control when provided by the surgeon, is included in the global surgical package and is not separately reimbursed. Placement of the pain pump catheter is also considered included in the allowance for the primary procedure. For example, insertion of a non-biodegradable drug delivery implant catheter is an integral part of trans- catheter therapy by infusion. CPT codes 11981 and 61650 are often incorrectly billed for placement of a pain pump catheter for postoperative pain control at the time of the primary procedure.
- Procedures or services where the CMS written policy states to deny when billed with a more comprehensive or related procedure.
- Lysis of adhesions that are not extensive and don’t require significant additional time when performed with another surgical procedure.
- Exploratory and “scout” procedures (e.g., exploratory laparotomy) followed by a definitive procedure.
- “Separate Procedure” codes as defined by CPT when performed with a more comprehensive procedure.
- Unlisted codes when used to represent an “incidental” service:
- CPT code 29999 used to report Iliopsoas recession surgery AND billed with hip arthroscopy procedures codes 29861-29863 and 29914-29916.
- CMS Status Indicator ‘T’ codes.
The NCCI code pairs, our CCE code pairs and ClaimsXten Unbundled code pairs define when two codes may not be reported together except under special circumstances. When these special circumstances are met, the proper modifier should be appended to the appropriate code to describe the circumstances. Bundling edits are applied in ClaimsXten. More information about ClaimsXten editing can be found in the ClaimsXten Editing section of our Coding Toolkit.
NCCI-associated modifiers, as defined by CMS, are accepted by our health plan as an indication of special circumstances which may allow codes to be reported together. For the NCCI code pairs, our health plan follows the CMS modifier indicator rules for determining whether a special circumstance could be indicated by a modifier.
However, our health plan has determined through review of the medical records that bypass modifiers are frequently used inappropriately on certain code pairs. These code pairs will continue to trigger an NCCI or CCE denial even when a bypass is appended. Lists of those code pairs associated with each of these modifiers is available on our health plan’s Provider Website.
It is important that modifiers only be used when appropriate. For the purposes of NCCI and CCE, these circumstances relate to separate patient encounters, separate anatomic sites, or separate specimens. The submission of a claim with a modifier appended to a code indicates that documentation is available in the patient’s records for review upon request that will support the use of the modifier.
The following are NCCI-associated modifiers:
