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Outpatient Hospital CCI Editing Policy, Facility - 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. 

 

Policy Codes

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  • 23700
  • 29823
* COMM-Outpatient-Hospital-CCI-Editing-Policy-Facility.pdf
Click to Download: Outpatient Hospital CCI Editing Policy, Facility - Reimbursement Policy - UnitedHealthcare Commercial Plans

Questions & 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.

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: 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 that address situations in which a modifier applies.  While the CCI Editing Policy recognizes many modifiers, those modifiers should only be 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.

Q: Which version of the Correct Coding Initiative (CCI) edits does UnitedHealthcare apply to this policy?

A: In accordance with CMS, UnitedHealthcare applies the hospital version of the CCI edits that are loaded in the Medicare Outpatient Code Editor (OCE).