CCI Editing Policy - Reimbursement Policy - UnitedHealthcare Commercial Plans

Overview

According to the Centers for Medicare and Medicaid Services (CMS), medical and surgical procedures should be reported with the CPT®/HCPCS codes that most comprehensively describe the services performed. For the purpose of this policy, the Same Individual Physician or Other Health Care Professional is the same individual rendering health care services reporting the same Federal Tax Identification number.

Policy Codes

Find your specific codes below.

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  • 23700
  • 28285
  • 28296
  • 29823
* COMM-CCI-Editing-Policy.pdf
Click to Download: CCI Editing Policy - Reimbursement Policy - UnitedHealthcare Commercial Plans

Questions and Answers

Q: Why does this UnitedHealthcare reimbursement policy not contain all CCI edits?

A: CCI edits may be addressed within other UnitedHealthcare reimbursement policies and therefore, are not included in this policy. Please refer to the Claims Estimator (available via UnitedHealthcareonline.com) to review appropriate bundling under all UnitedHealthcare policies.

Q: Will UnitedHealthcare allow both codes of a CCI edit to be reimbursed?

A: Yes, UnitedHealthcare will allow each code of a CCI edit pair to be separately reimbursed if the above listed modifiers are appropriately used. The separately reimbursed procedure and/or service must meet the criteria per the modifier definition. For example, modifier T1 is used to identify a procedure or service that is performed on the second digit of the left foot. Therefore, modifier T1 could be appended to code 28285 indicating a hammertoe procedure was performed on the second digit of the left foot at the same time as a bunionectomy procedure was performed on a separate anatomical site (i.e., 28296 with modifier LT) and both procedures would be allowed. The NCCI PTP edit indicates that the two codes generally should not be reported together unless the two corresponding procedures are performed at two separate patient encounters or two separate anatomic sites.

Q: Why does UnitedHealthcare not reimburse a NCCI Column Two (deny) code when it is reported with a NCCI designated modifier included in this policy?

A: NCCI edit has a modifier indicator assignment which specifies whether a modifier will bypass the edit. A modifier assignment of "0" does not allow a modifier to bypass the edit.

Q: What is the difference between Medicare NCCI edits and Medicaid NCCI Edits?

A: CMS administers Medicare NCCI edits on a national level whereas Medicaid NCCI edits are administered at a state level. The Medicaid NCCI program is derived from the Medicare NCCI program with modifications relevant tothe Medicaid program. CMS has worked with states to develop specific PTP edits for each state because of differences in state Medicaid programs and laws and regulations. In order to avoid confusion between the two programs, the Medicaid NCCI program uses the term NCCI PTP to identify its NCCI column one/column two edits.

Q: Since the CCI Editing policy recognizes many modifiers, do all modifiers bypass bundling edits in every situation?

A: No. There are many coding guidelines provided within credible third-party sources including, but not limited to, the CPT and HCPCS books, and CMS NCCI Policy Manual which address situations in which a modifier applies. While the CCI Editing policy recognizes many modifiers, modifiers only apply when they are used according to correct coding guidelines. For example, CMS considers the shoulder to be a single anatomic structure. An NCCI procedure to procedure edit code pair consisting of two codes describing two shoulder procedures should never be bypassed with an NCCI-associated modifier when performed on the ipsilateral (same side) shoulder. In this case, procedure 23700 is billed with modifier LT and is performed at the same encounter as procedure 29823 with modifier LT. Since both services were performed on the same (left) shoulder, only one procedure would be allowed.

If the two procedures are performed on contralateral (opposite) shoulders (23700 with modifier LT and 29823 with modifier RT) then the CCI edit would not apply.