When considering “bundled services,” we usually think of the National Correct Coding Initiative (NCCI) edits published by CMS.1 The “bundles” mean that Medicare expects a claim for the primary procedure but not for incidental services. Additionally, those codes identified as “mutually exclusive” cannot be reimbursed together in the same session. CMS developed NCCI to prevent inappropriate payment for services that should not be reported together. The edits are updated quarterly.
Although those instructions do account for many bundling edits, do not overlook instructions in the CPT manual itself. Look for restrictive language in the code descriptions, such as “with or without,” “may include,” or “with (additional steps).” Consider the following examples.
- 66150: Fistulization of sclera for glaucoma; trephination with iridectomy
- 66185: Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft
- 66852: Removal of lens material; pars plana approach, with or without vitrectomy
Also, read the parenthetical instructions associated with a code description, as in the examples below.
- 66174: Transluminal dilation of aqueous outflow canal; without retention of device or stent (Do not report 66174 in conjunction with 65820)
- 66185: Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft (Do not report 66185 in conjunction with 67255)
The phrase “separate procedure” within the CPT description is restrictive in a manner similar to NCCI. CPT instructs, “Some of the procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term, ‘separate procedure’. The codes designated as ‘separate procedure’ should not be reported in addition to the code for the total procedure or service of which it considered an integral component.”2 Consider the examples below.
- 65800: Paracentesis of anterior chamber of eye (separate procedure)
- 65865: Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae
- 66682: Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (eg, McCannel suture)
Finally, review the instructions for billing during the global surgery period.3
CMS Edits
Under some carefully defined circumstances, these bundles can be separated into their component parts and reimbursed discretely. Within the Medicare program, there are 2 types of edits4:
- Correct coding edits identify pairs of services that normally should not be billed by the same physician for the same patient on the same date of service.
- Mutually exclusive edits identify procedures that cannot reasonably be performed together based on the code definitions or anatomic considerations.
Although these edits were formerly published in 2 files, they are now combined in a single column 1/column 2 correct coding edit file, also known as the procedure to procedure (PTP) table. It requires careful reading of the PTP table to discern both kinds of edits.
Within NCCI’s correct coding edits, unbundling is permitted when the codes are assigned a “1” indicator (provided requirements are met and reported with the appropriate modifier), but not when they are assigned a “0” indicator. Examples of bundled ophthalmic services, with superscripts to identify the indicator, include the following:
- Severing anterior synechiae (658701) is bundled with complex cataract surgery (66982) and may be unbundled.
- Remote imaging of retina (922270) is bundled with fundus photography (92250) and may not be unbundled.
Examples of mutually exclusive edits include the following:
- Laser peripheral iridotomy (66761) and cataract surgery (66984); the higher value code, 66984, is billed, and not the iridotomy.
- Trabeculectomy (66170) and implantation of aqueous drainage device (0191T); the higher value code, 66170, is billed and not the device.
- Scanning computerized ophthalmic diagnostic imaging of optic nerve (92133) and fundus photography; the higher value code, 92250, may be billed; however, the diagnostic test with the greatest utility is a better determinant of the proper code to submit.
Unbundling
Starting with the premise that unbundling is the exception and not the usual order of the day, CPT instructs, “Modifier -59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.”5
CMS established the X-modifiers, X{ESPU}, in 2015 in lieu of modifier -59 to provide further clarity and granularity.6 CMS instructs that modifier 59 should be used only in situations that do not fit the descriptions of the X{ESPU} modifiers – those are few and far between. The X-modifiers are not described in the CPT book. Other third party payers are not obliged to follow Medicare guidelines, although many do.
- XE, Separate Encounter: Used when the procedures are performed in different encounters on the same day.
- XS, Separate Structure: Used when procedures are performed on different organs, in different anatomic regions, or in limited situations on different, noncontiguous lesions in different anatomic regions of the same organ.
- XP, Separate Practitioner: Used when the procedure are performed by different practitioners.
- XU, Unusual Nonoverlapping Service:
- Used when 2 services described by timed codes and provided during the same encounter are performed sequentially, and the blocks of time are separate and distinct.
- Used when a diagnostic procedure that is the basis for performing therapeutic procedure precedes the therapeutic procedure.
- Used when a diagnostic procedure is performed subsequent to a therapeutic procedure but is not common, not expected, not necessary follow-up for the procedure.
On July 15, 2021, CMS published a clarification regarding the use of the -59 modifier, as well as the X-modifiers.7 The clarification stated that these modifiers do not require the use of a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for the use of modifiers -59 or -X{EPSU}. Also, modifiers -59 or -X{EPSU} are not appropriate if the basis for their use is that the CPT description of the 2 codes is different.
Case Study 1
In your office, you perform gonioscopy (92020) as part of a glaucoma evaluation and schedule a laser trabeculoplasty (65855) at the hospital later the same day. A goniolens is used to perform the laser. In the NCCI correct coding edits, 92020 is bundled with 65855 but 92020 carries an indicator of “1,” and there is no mutually exclusive edit. Your claim will append modifier -XE to 92020 because gonioscopy was performed at a different encounter on the same day (ie, an office encounter and a hospital encounter).
Case Study 2
You examine a patient with glaucoma OU. You order OCT of the optic nerve (92133) and fundus photos (92250), which are captured on the same instrument at the same time. In the NCCI PTP file, CMS defines 92133 and 92250 as mutually exclusive, so they cannot be unbundled. Bill only 92250, the higher value procedure.
Case Study 3
One month after a being hit in the eye with a baseball, a patient is seen for complaints of marked reduction in vision. A traumatic cataract and vitreous prolapse into the anterior chamber are noted in the injured eye. You perform cataract surgery (66984) with an anterior vitrectomy (67010). In the NCCI PTP file, 67010 is bundled with 66984, and 67010 has an indicator of “1,” so they can be unbundled; there is no mutually exclusive edit. The documentation, in this case, does not support a different session, procedure, surgery, site or organ system; separate incision or excision; separate lesion; or separate injury. Consequently, unbundling is not justified. Do not use modifier -59 or -X{EPSU} in this situation. Only bill 66984.
Conclusion
Coding bundles can be confusing for billers and frustrating for providers who feel they are performing services for which they are not getting paid. Understanding the edits, and when and how to accurately identify a distinct procedure, is critical to reducing claims errors. GP
References
- Centers for Medicare and Medicaid Services. NCCI Policy Manual for Medicare Services. Accessed September 30, 2021. https://www.cms.gov/medicare/national-correct-coding-initiative-edits/ncci-policy-manual-medicare
- American Medical Association. CPT 2021: professional edition, surgery guidelines. Author; 2020.
- Medicare Claims Processing Manual, Chapter 12, §40. Accessed September 30, 2021. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
- Centers for Medicare and Medicaid Services. How to use the Medicare National Correct Coding Initiative (NCCI) tools. Accessed September 30, 2021. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf
- 2021 CPT Professional Edition, Appendix A, Modifiers.
- MedLearn Matters Fact Sheet, Proper Use of Modifiers 59 & -X{EPSU}. Accessed September 30, 2021. https://www.cms.gov/files/document/proper-use-modifiers-59-xepsu.pdf
- Centers for Medicare and Medicaid Services. CR 12311. Accessed September 30, 2021. https://www.cms.gov/files/document/r10878cp.pdf