"Unbundling" is a hot topic within the healthcare community and is considered fraudulent if done intentionally to maximize payment. Unbundling occurs when multiple CPT codes are billed for the component parts of a procedure when there is a single code available that includes the complete procedure.The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI or CCI) edits to prevent inappropriate payment of services that should not be reported together. Since 1996, CMS has used NCCI edits such as "mutually exclusive" to include tables of code pairs that, when billed together, will result in the second code of the pair being denied.

Some code pairs allow a modifier to be used to override the NCCI edit. Many commercial payers also utilize the NCCI tables to edit claims and for coding compliance.

The NCCI tables are updated quarterly. In fact, there were 5,245 additional NCCI code pairs added in the current quarter alone.

For example, the codes in the area of allergen immunotherapy (CPT codes 95115 through 95180) now include the codes for allergy testing and ingestion challenge testing (CPT codes 95004 through 95079). Codes from these groups may not be reported together. A modifier may be used to override this edit. Two common modifiers that may be used include: modifier 59 and modifier 79.

• Modifier 59 - Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/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/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.  

Note, effective January 1, 2015, four new modifiers that are a subset of modifier 59 will go into effect. For more details, please read the related Context blog article, The “X” Factor: 4 New Modifiers Will Define the Use of - 59 in 2015.

• Modifier 79 - Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period: The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79.

Other modifiers that may override a NCCI edit are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, RT, LT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, 25, 27, 58, 78, 91, LM, R1, 24, and 57.

Payers can monitor adherence to code pair edits and correct modifier usage by incorporating the NCCI edits into the claims editing process. Identifying the commonly used modifiers on claims can also help identify modifier misuse and outliers that may need further investigation.

Payers can rely on Context 4 Healthcare's Fraud, Waste & Abuse solution. The Context⁴ Healthcare Fraud, Waste and Abuse (FWA) Module of FirstPass^TM starts with real-time claims analysis during the adjudication cycle, while you’re still calculating your claim liability. FirstPass^TM contains thousands of rules consisting of millions of editing combinations, many of which are designed to identify potential FWA conditions. Additionally, the rules include evaluation of billed charges against our proprietary national Usual, Customary & Reasonable (UCR) fee schedule to find claims with charges out of the national norm for a service. These claims are identified and brought to your attention for follow up and compliance review. As claims are processed, the FirstPass^TM FWA Module ensures that claims meet one or more of our potential FWA rules and alerts your processors to the situation so further analysis and investigations can begin.

At Context, we analyze billions of claims each year, and as part of this process we frequently find out-of-the-ordinary claim submissions that have potential for FWA activity. Utilization, regulatory, bundling, unbundling, and provider verification edits are some of the edit categories included in the FWA module.