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Q&A: Mutually exclusive procedures, or other code combinations, won't pass NCCI edits

APCs Weekly Monitor, February 13, 2009

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Q. When physicians perform procedures that they can either perform alone or together with a more comprehensive procedure, should we submit a separate charge for the component procedure, or roll the charge into the more comprehensive procedure? Assuming it is not appropriate to append a modifier, if we bill on separate lines, is it better to leave the CPT code on the claim without a modifier, or remove the CPT code and just bill the appropriate revenue code with the charges?

A. When procedures edit for being mutually exclusive or for one procedure being included in the code for another procedure, the combination of codes won’t pass the NCCI edits. The bundled CPT code will hit an edit that will reject the code from your claim, possibly causing rejection of covered charges as well. Therefore, when you identify bundled procedures, you should resolve the error before submitting your claims rather than simply submitting without a modifier and letting the edit remove the line item all together. If the edit just removes the line item, CMS may not capture correct costs for future rate-setting.

You mention one option: to bill the charge on a revenue code line without the HCPCS code. One of the problems with this is that many revenue codes require a HCPCS code. You also mention incorporating the charge into the associated procedure, which is a viable option. With either of these methods, it is imperative that you confirm that the costs of the bundled procedure are not already incorporated into the comprehensive procedure’s charge. If they are, you need to remove the line item altogether to prevent an overcharging situation.

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