If I receive a denial for a procedure bundled into another service, and I cannot find this code pair in the column 1/column 2 correct coding list of edits, where else should I look?
Look in the mutually exclusive code list. The mutually exclusive code edits in the printed version of the CCI Edits Manual are in the same chapter but separate from the column 1/ column 2 correct coding edits. The electronic version of the mutually exclusive code edits that is available on the CMS website can be found in a separate listing at http://www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp, which are arranged by specific chapters.
What exactly does “column 1” mean in the column 1/column 2 correct coding edits table and in the mutually exclusive edits table?
Formerly known as the “comprehensive code” within the column 1/column 2 correct coding edits table, the column 1 code generally represents the major procedure or service when reported with the column 2 code. When reported with the column 2 code, “column 1” generally represents the code with the greater work RVU of the two codes.
However, within the mutually exclusive edits table, “column 1” code generally represents the procedure or service with the lower work RVU, and is the payable procedure or service when reported with the column 2 code
Claims Review for Global Surgeries
A.Relationship to Correct Coding Initiative (CCI)
The CCI policy and computer edits allow A/B MACs (B) to detect instances of fragmented billing for certain intra-operative services and other services furnished on the same day as the surgery that are considered to be components of the surgical procedure and, therefore, included in the global surgical fee. When both correct coding and global surgery edits apply to the same claim, A/B MACs (B) first apply the correct coding edits, then, apply the global surgery edits to the correctly coded services.
B.Prepayment Edits to Detect Separate Billing of Services Included in the Global Package
In addition to the correct coding edits, A/B MACs (B) must be capable of detecting certain other services included in the payment for a major or minor surgery or for an endoscopy. On a prepayment basis, A/B MACs (B) identify the services that meet the following conditions:
*Preoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure; or
*Same day or postoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure or endoscopy;
and –
*Services that were furnished within the prescribed global period of the surgical procedure;
*Services that are billed without modifier “-78,” “-79,” “-24,” “25,” or “-57” or are billed with modifier “-24” but without the required documentation; and
*Services that are billed with the same provider or group number as the surgical procedure or endoscopy. Also, edit for any visits billed separately during the postoperative period without modifier “-24” by a physician who billed for the postoperative care only with modifier “-55.”
A/B MACs (B) use the following evaluation and management codes in establishing edits for visits included in the global package. CPT codes 99241, 99242, 99243, 99244,
99245, 99251, 99252, 99253, 99254, 99255, 99271, 99272, 99273, 99274, and 99275
have been transferred from the excluded category and are now included in the global surgery edits.
Evaluation and Management Codes for A/B MAC (B) Edits
92012 92014 99211 99212 99213 99214
99215 99217 99218 99219 99220 99221
99222 99223 99231 99232 99233 99234
99235 99236 99238 99239 99241 99242
99243 99244 99245 99251 99252 99253
99254 99255 99261 99262 99263 99271
99272 99273 99274 99275 99291 99292
99301 99302 99303 99311 99312 99313
99315 99316 99331 99332 99333 99347
99348 99349 99350
99374 99375 99377 99378
NOTE: In order for codes 99291 or 99292 to be paid for services furnished during the preoperative or postoperative period, modifier “-25” or “-24,” respectively, must be used to indicate that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed.
If a surgeon is admitting a patient to a nursing facility for a condition not related to the global surgical procedure, the physician should bill for the nursing facility admission and care with a “-24” modifier and appropriate documentation. If a surgeon is admitting a patient to a nursing facility and the patient’s admission to that facility relates to the global surgical procedure, the nursing facility admission and any services related to the global surgical procedure are included in the global surgery fee.
C.Exclusions from Prepayment Edits
A/B MACs (B) exclude the following services from the prepayment audit process and allow separate payment if all usual requirements are met:
Services listed in §40.1.B; and
Services billed with the modifier “-25,” “-57,” “-58,” “-78,” or “-79.” Exceptions
See §§40.2.A.8, 40.2.A.9, and 40.4.A for instances where prepayment review is required for modifier “-25.” In addition, prepayment review is necessary for CPT codes 90935, 90937, 90945, and 90947 when a visit and modifier “-25” are billed with these services.
Exclude the following codes from the prepayment edits required in §40.3.B.
92002 92004 99201 99202 99203 99204
99205 99281 99282 99283 99284 99285
99321 99322 99323 99341 99342 99343
99344 99345
