What is CCI?
While I was speaking in Atlanta, GA last week I had a doctor ask me a question about getting a denial for the following clinical situation:
A 26 year old patient presented with a corneal abrasion of his right eye and I evaluated him and debrided loose epithelium from his cornea and then placed a bandage contact lens on that eye and prescribed polytrim QID OD. We submitted a 99212, 65435 and 92071. We got denied payment for the 99212 and the 92071, what modifiers do we need to use to get paid?
There is a significant amount to discuss in this question but you can check out the last blog post to see why if we were only discussing the office visit why the 99212 would be significantly undercoded.
As for the details of this question let's take a look at the National Correct Coding Initiative (NCCI). According to CMS, they:
"[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."
This means that we need to understand which codes bundle other codes.
When it comes to billing office visits with surgical codes it is important to understand that:
For major surgical procedures (eg: cataract surgery, 90 days) you CAN bill an office visit on the same day as the surgical procedure if a -57 modifier is used, even if the office visit is directly related to the evaluation of the condition leading to the surgical procedure
For minor surgical procedures (eg: corneal debridement, 10 days or less) the evaluation of the condition is included in the code and payment for that procedure
It is important to note that if there is a separately identifiable evaluation and management service performed that is unrelated to the minor surgery that service is billable with a -25 modifier
When it comes to billing for bandage contact lenses (92071) the CCI provides the following guidance:
"CPT code 92071 (fitting of contact lens for treatment of ocular surface disease) shall not be reported with a corneal procedure CPT code for a bandage contact lens applied after completion of a procedure on the cornea."
Now we can put it all together and many of you will not like the answer:
Since the evaluation and management services are included in the corneal debridement code (since it is minor surgery) AND fitting of bandage contact lens are included in the corneal debridement code, we would bill simply the 65435.
If, however, the patient presented with a corneal abrasion that didn't need debridement then you would likely bill the 99212 (likely undercoded) and the 92071.
Want to learn how to utilize codes simply and accurately?