Denial reason 6. Bundled Services

MRA reason code CO-125: Submission/billing error(s) (National Correct Coding Initiative (NCCI)).

· Remark message M15: Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.

MRA reason code CO-97 (global services): The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

· MRA reason code M144: Pre-/postoperative care payment is included in the allowance for the surgery/procedure.

· MRA reason code N109: This claim was chosen for complex review and was denied after reviewing the medical records.

Resolution

CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association’s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.

NCCI edits are pairs of CPT or HCPCS Level II codes that are not separately payable except under certain circumstances. The edits are applied to services billed by the same provider for the same beneficiary on the same date of service. All claims are processed against NCCI tables.

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

Codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1, unless the edits permit the use of a modifier associated with NCCI. Column 1 generally represents the major procedure or service and Column 2 often represents the component part of the Column 1 code. However, within the mutually exclusive edits table, the Column 2 code generally represents the procedure or service with the higher work Relative Value Unit (RVU) and is the non-payable procedure or service when reported with the Column 1 code.

Each code pair (Column 1/Column 2 correct coding edits and mutually exclusive code edits) is assigned a correct coding modifier indicator of either “0,” “1” or “9.”

The indicators mean:

· 0 – There are no modifiers associated with NCCI that are allowed to be used with this code pair; there are no circumstances in which both procedures of the code pair should be paid.

· 1 – The modifiers associated with NCCI are allowed with this code pair when appropriate.

· 9 – This indicator means NCCI edits do not apply to this code pair. The edits have been deleted for this code pair.

When applicable, there are modifiers that are applied to Column 2 codes that may allow payment when the code pair has a “1” indicator. They are:

· Anatomical modifiers.

· Miscellaneous modifiers.

· Global surgery modifiers.

· Modifier 91.

· Modifier 59.

The cost of care before and after surgery is included in the approved amount for that service.

Services rendered by the same provider within the global period of a major surgery, minor surgery or endoscopic procedures are considered as included in the allowance for the surgical/endoscopic procedure.

There are numerous modifiers to assist providers in notifying Medicare of instances when the service should be considered separately from the surgical procedure.

Modifiers to report payable services within a global period are:

· 24 modifier: Unrelated Evaluation and Management (E/M) service by the same physician during a postoperative period. The physician may need to indicate that an E/M service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level E/M service.

· 25 modifier: Significantly separately identifiable E/M service by the same physician on the same day of the procedure or other service. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding the 25 modifier to the appropriate level of E/M service.

· 57 modifier: Decision for surgery. An E/M service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level E/M service.

Note: Modifiers 24, 25 and 57 apply to E/M CPT codes only.

· 58 modifier: Staged or related procedure or service by the same physician during the postoperative period. It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding the modifier 58 to the staged or related procedure.

Note: For treatment of a problem that requires a return to the operating or procedure room (e.g., unanticipated clinical condition), see modifier 78.

· 78 modifier: Return to the operating room for a related procedure during the postoperative period. An “operating room” is defined by Medicare as any place of service specifically equipped and staffed for the sole purpose of performing procedures.

The 78 Modifier will create a reduction in the allowance.

· 79 modifier: Unrelated procedure or service by the same physician during the postoperative period. The physician may need to indicate the performance of a procedure or service during the postoperative period was unrelated to the original procedure.

Note: Modifiers 58, 78 and 79 on surgical CPT codes only during a global surgical period.