At this time, everyone is fairly well acquainted with the National Correct Coding Initiative (NCCI) edits published by CMS.¹ The “bundles” included in those mean that you bill for the primary procedure but not for incidental services. Additionally, those codes identified as “mutually exclusive” cannot be reimbursed together in the same session. CMS developed NCCI to prevent inappropriate payment for services that should not be reported together. The edits are updated quarterly

Although those instructions account for many bundling edits, do not overlook instructions in the CPT manual itself. Watch out for restrictive language in the code descriptions, such as, “with or without,” “may include,” or “with (additional steps).”

Q. What are some examples of CPT bundles?

A. Consider these (bold added for emphasis):

• 67042: “Vitrectomy, … pars plana … with removal of internal limiting membrane … includes, if performed, intraocular tamponade … ”
• 67108: “Repair of retinal detachment; … with vitrectomy, any method including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling and/or removal of lens by same technique”
• 67113: “Repair of complex retinal detachment … with vitrectromy and membrane peeling, including, when performed … tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens”

Also, read the parenthetical instructions associated with a code description; they can guide you when another code is supported. For example, 67113, “(To report vitrectomy, pars plana approach, other than in retina detachment surgery, see 67036-67043).”

Q. What other instructions should we look for in CPT?

A. The phrase “separate procedure” within the CPT description is restrictive in a manner similar to NCCI. CPT instructs, “Some of the procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term, ‘separate procedure’. The codes designated as ‘separate procedure’ should not be reported in addition to the code for the total procedure or service of which it considered an integral component.”² One example is 67028, “Intravitreal injection of pharmacologic agent (separate procedure).”

Q. What else do I need to know?

A. Review the instructions for billing during the global surgery period.³ Although global surgery periods are set by Medicare and other payers and are not a CPT instruction, CPT does identify “one or more sessions” or discusses “a defined treatment period.” See the following instructions: “Codes … include treatment at one or more sessions that may occur at different encounters” and “… should be reported once during a defined treatment period.”

• 67145: “Prophylaxis of retinal detachment … without drainage, 1 or more sessions; photocoagulation”
• 67210: “Destruction of localized lesion of retina, 1 or more sessions; photocoagulation”

Interestingly, 67228 (PRP) does not include the “1 or more sessions” designation in CPT, although payer policy might apply the concept anyway.

Q. Back to NCCI edits, when can codes be unbundled appropriately?

A. Under some carefully defined circumstances, these bundles can be separated into their component parts and reimbursed discretely. Within NCCI’s correct coding edits, unbundling is permitted when the codes are assigned a “1” indicator (provided requirements are met and reported with the appropriate modifier), but not when they are assigned a “0” indicator. Examples of bundled ophthalmic services, with superscripts to identify the indicator, include the following:

• Anterior vitrectomy (67010¹) is bundled with cataract surgery (66984) and may be unbundled.
• Remote imaging of retina (92227⁰) is bundled with fundus photography (92250) and may not be unbundled.

Q. What about using modifier 59?

A. Starting with the premise that unbundling is the exception and not the usual order of the day, CPT instructs, “Modifier -59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury … not ordinarily encountered or performed on the same day by the same individual.”⁴ However, on July 15, 2021, CMS published a clarification regarding the use of the modifier -59 as well as the X-modifiers.⁵ Pertinent points from that transmittal include the following:

These modifiers do not require the use of a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for the use of modifiers -59 or -X{EPSU}.

Modifier -59 or -X{EPSU} are not appropriate if the basis for their use is that the CPT description of the 2 codes is different.

So, different diagnoses are not required for use of modifier -59 or the X-modifiers, but by the same token, they are also not sufficient support for unbundling. Likewise, different CPT codes will not always support separate claims. You need to look further than just ICD-10 or CPT codes. RP

REFERENCES

1. CMS. NCCI Policy Manual for Medicare Services. Accessed August 15, 2021. https://www.cms.gov/medicare/national-correct-coding-initiative-edits/ncci-policy-manual-medicare
2. 2021 CPT Professional Edition, Surgery Guidelines.
3. Medicare Claims Processing Manual, Chapter 12, §40. Accessed August 15, 2021. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
4. Corcoran S. Modifier 59 — you’re probably using it a lot, but are you using it correctly? Retin Physician 2015;12(3):20,21. Accessed September 15, 2021. https://www.retinalphysician.com/issues/2015/april-2015/coding-q-amp;a
5. CMS CR 12311. Accessed August 15, 2021. https://www.cms.gov/files/document/r10878cp.pdf