CCI Edits and Comprehensive APCs

on Tuesday, 22 August 2017. All News Items | FAQ


Our hospital is receiving Medicare denials for claims when the patient has outpatient dialysis (HCPCS code G0257) and a balloon angioplasty of the dialysis catheter (CPT 36905) during the same outpatient encounter.  We know CPT 36905 has a status indicator (SI) of J1 and payment for all adjunctive services will be bundled into the payment for that code.  We do not understand why we are not being paid at all for this claim


The most likely reason your claim is denying is because there is a procedure-to-procedure (PTP) National Correct Coding (NCCI) edit for the code combination G0257 and 36905. The outpatient dialysis code (G0257) is the column one code and the PTA (36905) is the column two code.  A modifier appended to the column two code (36905) is allowed to by-pass this edit. 

Even though there is no separate payment for the outpatient dialysis due to the “J1” packaging, Medicare still applies NCCI edits to all codes submitted on the claim.  If there is a PTP CCI edit for a code combination on the claim that is not modified to by-pass the edit, that line item will deny.  In this case, all of your payment is associated with the denied line item and there is $0 payment for the entire claim.

We have also seen denials for services that pay separately under the J1 packaging, such as brachytherapy sources which have an SI of “U”.  The brachytherapy source denied because a modifier was not added to the HCPCS code to by-pass a CCI edit. In one example the brachytherapy source (HCPCS C2616) was billed with radiopharmaceutical localization of a tumor (CPT 78800).  There is a PTP edit for this code combination with C2616 being the column two code.  As such it requires a modifier to by-pass the edit and allow separate payment when reported with a J1 comprehensive APC.

Most hospitals’ billing systems have Medicare pre-claim submission edits that alert the billers when an NCCI PTP code combination without a modifier to by-pass the edit is reported. The billers should have clear guidance, procedures, and assistance in determining when the addition of a modifier is appropriate.  This is especially important for high-dollar claims where the facility stands to lose a substantial amount of reimbursement if denied.


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