Bundling

National Correct Coding Initiative edits need case-by case consideration.

In February 2004, you received a request from Medicare for copies of medical records supporting previously paid claims for codes 66984 (cataract surgery with IOL) and 67010-59 (removal of vitreous, subtotal removal with mechanical vitrectomy). The charts requested were for services rendered over a 1-year period in 2002. The audit resulted in denials for the services and an overpayment request. In the opinion of Medicare’s reviewer, the charge for 67010-59 was unjustified and should have been denied as an incidental component of cataract surgery, that is, “bundled” under the National Correct Coding Initiative (CCI).

Was the Medicare carrier determination accurate?

The Center for Medicare and Medicaid Services developed the National CCI to promote correct coding methodologies. CCI edits are based on coding conventions defined in the American Medical Association’s Current Procedural Terminology Manual, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practices. The edits are updated quarterly with an effective date of the first of every quarter. Edits are not retroactive but are effective from the designated date.

The CCI edits contain numerous code combinations that have been bundled together as well as codes that are considered mutually exclusive. The bundles simply mean that Medicare expects to receive a claim for the primary procedure but not for the incidental procedures. Those codes listed as “mutually exclusive” cannot be reimbursed together in the same session.

In this case, the Medicare reviewer determined that the vitrectomy should have been bundled with the cataract surgery as described in the CCI edits. The use of modifier -59 was inappropriately applied and facilitated unbundling the vitrectomy for payment.

Upon receipt of the overpayment request, the practice administrator began an internal review to determine the cause of this error and the accuracy of the overpayment request. The internal review revealed an inexperienced data entry person appended modifier -59 to these claims because she believed that the vitrectomy was a distinct, reimbursed procedure.

You reviewed all claims involved and determined that two cases should be paid for both the cataract surgery and the anterior vitrectomy. These two cases involved a pre-planned vitrectomy with cataract surgery. Both patients had traumatic cataracts, and their initial exams revealed vitreous in the anterior chamber. The preoperative plan included cataract surgery with implantation of an IOL and an anterior vitrectomy. The documentation of medical necessity for both procedures exists in the patient’s office note, and the operative report describes the plan and completion of both procedures.

You supply chart notes and operative reports for these two cases, and the carrier reversed the overpayment on them. You agree that the remaining cases involved an incidental vitrectomy resulting from an intraoperative event. The overpayment request for these cases was accurate.

Practices should report procedures with the most comprehensive code describing them, taking into consideration that additional procedures may be incidental and not separately billable. The use of modifier -59 should be rare. Usually, unbundling occurs because of a misunderstanding of coding principles. But unbundling may also be intentional to manipulate the system and maximize reimbursement. Take the time to educate physicians and staff on the purpose and use of the CCI edits.