How to use CCI edit when procedure denied as bundled service

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                

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