CCI 16.0 is coming out: Do you know what you need to know to get your claims paid and stay compliant.

I once talked with a man who owns a billing company. When a physician practice claims are denied, the billing company lets the practice know the reason why. Often, the billing company owner reports, CCI edits are causing the denials. But because the practices don’t understand CCI very well, they don’t understand when they can override the edit. Lots of folks leave lots of rightful reimbursement on the table because CCI seems so intimidating, he told me.

Bottom Line: If you don’t understand what Correct Coding Initiative (CCI) edits are, how they work, and how they affect your claims, you’re risking denials, fraud charges, and lost reimbursement.

Check out these expert answers to 3 common CCI questions and sharpen your coding skills today.

1. What Is a CCI Edit?

Every quarter CCI puts out a list of code pairs that Medicare — and many 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 together. Medicare applies these 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),” explains Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, consultant with MJH Consulting in Denver. “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 CCI.”

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

2. Why Are There 2 Edit Types?

CCI edits include two types of edits: mutually exclusive and “column 1/column 2” edits.

Here’s the difference: Mutually exclusive edits pair procedures or services that the physician could not reasonably perform at the same session on the same beneficiary. For example, CCI lists 60252 (Thyroidectomy, total or subtotal for malignancy) as mutually exclusive of 60260 (Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid). The doctor could not perform a total thyroidectomy and remove tissue following a previous removal of a portion of thyroid at the same session.

Column 1/column 2 edits describe “bundled”procedures. CMS considers the code listed in column 2 included as a component of the more extensive column 1 procedure.

The first column in the CCI Excel spreadsheet “generally represents the major procedure or service”and the code in the second spreadsheet column “often represents the component part,” Hammer says. “However, within the mutually exclusive edits table, the column 2 code generally represents the procedure or service with the higher work RVU and is the nonpayable procedure or service when reported with the column 1 code.”

Payment woes: If you bill two mutually exclusive codes for the same patient during the same session, payers following CCI rules will reimburse only for the lesservalued of the two procedures.Conversely, if you bill bundled (column 1/column 2) procedures for the same patient during the same session, payers will pay you only for the higher-valued of the two.

3. Can I Ever Ignore the Edits?

In certain clinical circumstances you can override — not ignore — CCI edits and receive separate reimbursement for bundled codes. To find out if you can separately bill services your physician performed,first check the “modifier indicator”in column F of the CCI spreadsheet.

A “0” indicator means that you cannot unbundle the two codes under any circumstances. An indicator of “1,” however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate reimbursement, such as a separate encounter on thesame date, a separate anatomical site, or a separate indication.

Tip: Do not append a modifier to override a CCI bundle just to get paid or because you do not agree with a bundle. You can use a modifier to override a bundle only if your documentation supports using the modifier.

Adapted from Part B Insider. Download your 2 FREE sample issues here.

Have you tried Supercoder’s CCI Validation Tool? Sign up for a 30-day free trial and get the tool, plus official code descriptors and top-notch how-to articles.

Finally. Tips to help you actually USE the data you download from CMS.

If the Microsoft Excel files you download from CMS make your hair stand on end, help is here!

CCI Excel files are impossible to work with because some of the data that isn’t in the correct format, explains Kara Hiltz, who writes Inside Microsoft Excel.

That’s why you notice all of the green triangles in your cells’ upper-left corners,which Figure A shows. Excel is letting you know that the cell contains a number formatted as text (instead of as a number). And the dates don’t have the correct formatting either, which means that Excel doesn’t recognize them as dates.

You can use the Text to Columns feature to correct these issues in seconds.

A: This Excel file has its data in all the wrong formats.

To change a column’s data to a number format:

1. Select cell A3 or whatever cell starts your column’s number data.

2. Press [Ctrl][Shift][down arrow] to select all of the data in the column below cell A3.

3. Choose Data | Text To Columns from the menu bar to open the Text To Columns wizard.

4. Click Finish to accept the wizard’s defaults.

Now all of the numbers in that column no longer have incorrect text formatting — and the green triangles flagging the cells disappear.

To change a column’s data to a date format:

1. Select cell D3 or whatever cell starts your column’s date data.

2. Press [Ctrl][Shift][down arrow] to select all of the data in the column below cell D3.

3. Choose Data | Text To Columns from the menu bar to open the Text To Columns wizard.

4. Click Next twice until you get to Step 3 of the wizard.

5. Select the Date option button and choose YMD from the corresponding dropdown list.

6. Click Finish to convert your dates.

B: Now your worksheet is ready for filtering & sorting.

Your worksheet should now resemble the one in Figure B. Now that your number and date values have the correct formatting, sorting and filtering the data becomes a breeze.

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