It’s Edit Time Again

The beginning of the year always brings new coding changes as well as other changes, such as updates to the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) guidelines and coding edits. It is important that you review the new guidelines and edits to identify their potential impact to your charge capture process within your organization. The manual is located on the CMS website at the end of this article. 

To get into the details of diagnostic radiology edits you should first read Chapter 9 which includes guidelines for diagnostic radiology services. This chapter contains a great deal of helpful information. Interventional services are covered in other chapters corresponding to the procedure codes for those services (vascular, biliary, etc.)

Anyone involved with, or responsible for, ensuring radiology coding and charge capture should download a copy of the latest version of the manual and review it carefully. The manual is updated each year in the fourth quarter for the coming calendar year, and in December CMS will post the 2024 version of the manual. To make it easier to identify the changes from year-to-year CMS highlights the information with red text for additions and red strikethroughs for deletion. When you see red, that’s your cue to stop and read carefully because the information is either new or revised.  

Other payors also use bundling edits. Commercial payors and managed care plans may use some or all of the CCI edits and may also use their own proprietary edits that are not part of CCI. Typically, the edits consist of pairs of codes that should not normally be reported together. When the two codes are reported by the same provider for the same patient on the same date of service, the provider will receive payment for the higher-paying code that appears in Column 1 of the edits and will not be paid for the lower-paying code that appears in Column 2. This type of edit is referred to as a Procedure-to-Procedure (PTP) edits. The majority of radiology edits fall into this category.

The PTP edits also include mutually exclusive code pairs. These are pairs of services that cannot reasonably be performed at the same anatomic site or same patient encounter. With mutually exclusive code pairs, the lower-paying code is in Column 1 of the edits, so the provider will be paid only for the lower-paying service. There are very few radiology edits that are classified as mutually exclusive.

Each code pair has a modifier indicator that shows whether the edit can be bypassed with a modifier. If there are situations when it is appropriate to report the two codes on the same day – for example, if the procedures were performed during separate encounters or on different anatomic areas – then the code pair will have modifier indicator 1, meaning that the provider can use a modifier to show that the services were separate and distinct.  

However, if the code pair has modifier indicator 0, this means there are no circumstances under which Medicare would ever consider both services to be separate and distinct, and the Column 2 service will be denied even if a modifier is applied.

A second type of edits is the Medically Unlikely Edits (MUEs). According to CMS, MUEs are automated prepayment edits that help prevent inappropriate payments. An MUE for a HCPCS/CPT® code sets the maximum units of service allowed by Medicare for a single beneficiary on a single service date. In addition, MUEs do not exist for all procedure codes. CMS develops MUEs based on anatomic considerations, HCPCS/CPT® code descriptors, CPT® coding instructions, established CMS policies, the nature of the service or procedure, the nature of equipment used to complete the procedure, and clinical judgment. 

The third type of edits to the CCI collection are called Add-on Code edits. These edits consist of a list of add-on procedure codes together with their recognized base codes. Finally, the manual notes that although the base code and the add-on code will normally have the same date of service, there may be unusual circumstances where different dates of service apply.

You can find all of the CCI edit files by scanning the QR code below.

Edits can create confusion and frustration for anyone involved in the coding and charge capture process for radiology services. It is critical that the individuals responsible for reviewing patient charge information be very familiar with the edits and how they should be handled for radiology services. It is not as straightforward as determining whether we can bypass an edit. We must look to authoritative guidance to drive our decision-making process. Communication between radiology and revenue cycle staff is key and it should be viewed as an ongoing dynamic process.