claim editing update report: 4th quarter 2016 · blue cross and blue shield association....

Claim Editing Update Report: 4th Quarter 2016Page Section

1 McKesson Code Pair Additions Code pair edits added to the McKesson KnowledgePack Update. Site-specific modifier override indicators for denied/paid code combination. Y = does override; N = does not override; N/A = does not apply to the code combination.

4 McKesson Code Pair Rationale DescriptionsRationale descriptions for the rationale codes included in the McKesson Code Pair Additions section.

14 McKesson Code Pair ExpirationsCode pair edits closed from the McKesson KnowledgePack Update.

15 CCI V22.3 Additions Edits added in new version of CCI. Provides brief CCI policy for each edit.

1123 CCI V22.3 ExpirationsEdits that were closed in new version of CCI.

1125 CCI V22.3 ChangesChanges to modifier overrides (new override = 1 or no longer overrides = 0) for existing code pairs and changes to existing edits' effective and/or expiration date.

1126 CCI V22.3 Deletions Edits that were deleted in new version of CCI.

1132 OCE CCI V22.3 AdditionsEdits added in new version of OCE/CCI.

2240 OCE CCI V22.3 ExpirationsEdits that were closed in new version of OCE/CCI.

2242 OCE CCI V22.3 ChangesChanges to modifier overrides (new override = 1 or no longer overrides = 0) for existing code pairs and changes to existing edits' effective and/or expiration date.

2243 OCE CCI V22.3 DeletionsEdits that were deleted in new version of OCE/CCI.

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INSTRUCTIONS

Source Abbreviation Source Name Source Abbreviation Source NameAAOS American Academy of Orothopaedic Surgeons AUA American Urological Association.ACC American College of Cardiology. CCI Correct Coding Initiative .

ACOG American College of Obstetricians and Gynecologists. CCN External physician consultants.ACR American College of Radiology. CMS Centers for Medicare and Medicaid Services (CMS) coding guidelines.ACS American College of Surgeons DMEPOS DME Prosthetic, Orthotic, Supplies Fee ScheduleAMA CPT coding guidelines. HPP Health Plan Policy

AMA RBRVS AMA RBRVS Data Manager PPP Internal physicians.ASA American Society of Anesthesiologists. SMFM Society for Maternal-Fetal Medicine.ASM American Society for Microbiology. STS Society of Thoracic Surgeons.

Edit source abbreviations are defined below.

CCI Edits: CCI code pair edits are code pairs that should not be reported together for a number of reasons explained in the “National Correct Coding Initiative Coding Policy Manual for Medicare Services”. The CCI Additions tab contains new edits added by CCI (with policy statement). The CCI Expirations tab contains edits expired by CCI. The CCI Deletions tab contains edits deleted by CCI. The CCI Changes tab contains edits modified by CCI. Changes can include 1) Modifier Override (CCI "GB Indicator") modifications represented with a 'Modified' record and an 'Added' record, or 2) edit effective or expiration date modifications represented in one 'Modified' record. NOTE: An indicator of "1" = a modifier indicated by CCI can be used to allow payment for both codes. "0" = No modifier can be used to bypass the edit pair.

OCE/CCI Edits: CCI edits incorporated into Outpatient Code Editor (OCE). The OCE/CCI Additions tab contains new edits added by OCE/CCI (with policy statement). The OCE/CCI Expirations tab contains edits expired by OCE/CCI. The CCI Deletions tab contains edits deleted by OCE/CCI. The OCE/CCI Changes tab contains edits modified by OCE/CCI. Changes can include 1) Modifier Override (OCE/CCI "GB Indicator") modifications represented with a 'Modified' record and an 'Added' record, or 2) edit effective or expiration date modifications represented in one 'Modified' record. NOTE: An indicator of "1" = a modifier indicated by OCE/CCI can be used to allow payment for both codes. "0" = No modifier can be used to bypass the edit pair.

McKesson Code Pairs: This includes code pairs based on three of the rule types in the CXT UNBUN_PAIRS rule. These rule types are Incidental (INC), Mutually Exclusive (ME), and Parent/Child (ULT_PARENT) editing. An Edit Rationale number is provided with each McKesson Code Pair addition, which can be used to refer to the Edit Report Rationale worksheet where they are listed in numeric order. This Edit Rationale number is specific to this report only.

General Modifier Information: Modifiers -25, -57, and -59 are intended to indicate that a service/procedure that would normally be included in payment for another service/procedure should, for specific reasons, not be denied when submitted with one of these modifiers.By default, modifier -25 will override any edit within the McKesson Code Pair Additions tab where the RULE_TYPE is ME or INC as well as any edit described in the McKesson Visits tab.By default, modifier -57 will override any edit described in the McKesson Visits tab.By default, modifier -59 will override any edit within the McKesson Code Pair Additions tab where the RULE_TYPE is ME, INC, or ULT_PARENT."

The information contained in this report is intended to expedite review of Horizon BCBSNJ 2016 3rd quarter edit changes. Edits in the workbook are sorted first by denied code then by paid code in ascending numeric order. A '#' sign immediately

PLEASE REVIEW THE FOLLOWING IMPORTANT INFORMATION

CPT copyright 2016 American Medical Association. All rights reservedAll other product and company names may be trademarks or registered trademarks of their respective companies.

ClaimsXten™ is a trademark of McKesson Corporation.

McKesson Code Pair Additions

Rule Type

Denied Code

Denied Code Description

PaidCode

Paid Code Description Site override? AMA CMS

Rationale Code

Horizon Edit Eff. Date

INC A4213 20+ CC SYRINGE ONLY C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4215 STERILE NEEDLE C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4216 STERILE WATER/SALINE, 10 ML C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4217 STERILE WATER/SALINE, 500 ML C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4244 ALCOHOL OR PEROXIDE PER PINT C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4245 ALCOHOL WIPES PER BOX C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4246 BETADINE/PHISOHEX SOLUTION C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4247 BETADINE/IODINE SWABS/WIPES C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4248 CHLORHEXIDINE ANTISEPT C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4450 NON-WATERPROOF TAPE C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4452 WATERPROOF TAPE C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4455 ADHESIVE REMOVER PER OUNCE C9744 ABD US W/CONTRAST N X 124222 11/1/2016INC A4456 ADHESIVE REMOVER, WIPES C9744 ABD US W/CONTRAST N X 124222 11/1/2016INC A4550 SURGICAL TRAYS C9744 ABD US W/CONTRAST N X 122618 11/1/2016INC A4649 SURGICAL SUPPLIES C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4657 SYRINGE W/WO NEEDLE C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4927 NON-STERILE GLOVES C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4928 SURGICAL MASK C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC A4930 STERILE, GLOVES PER PAIR C9744 ABD US W/CONTRAST N X 125787 11/1/2016INC C9744 ABD US W/CONTRAST 99217 OBSERVATION CARE DISCHARGE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99218 INITIAL OBSERVATION CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99219 INITIAL OBSERVATION CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99220 INITIAL OBSERVATION CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99221 INITIAL HOSPITAL CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99222 INITIAL HOSPITAL CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99223 INITIAL HOSPITAL CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99224 SUBSEQUENT OBSERVATION CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99225 SUBSEQUENT OBSERVATION CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99226 SUBSEQUENT OBSERVATION CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99231 SUBSEQUENT HOSPITAL CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99232 SUBSEQUENT HOSPITAL CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99233 SUBSEQUENT HOSPITAL CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99234 OBSERV/HOSP SAME DATE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99235 OBSERV/HOSP SAME DATE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99236 OBSERV/HOSP SAME DATE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99238 HOSPITAL DISCHARGE DAY N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99239 HOSPITAL DISCHARGE DAY N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99251 INPATIENT CONSULTATION N X X 132256 11/1/2016

* Rationale Code descriptions are included beginning on page 2.1


Rule Type

Denied Code


PaidCode


Rationale Code


INC C9744 ABD US W/CONTRAST 99252 INPATIENT CONSULTATION N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99253 INPATIENT CONSULTATION N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99254 INPATIENT CONSULTATION N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99255 INPATIENT CONSULTATION N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99281 EMERGENCY DEPT VISIT N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99282 EMERGENCY DEPT VISIT N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99283 EMERGENCY DEPT VISIT N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99284 EMERGENCY DEPT VISIT N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99285 EMERGENCY DEPT VISIT N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99288 DIRECT ADVANCED LIFE SUPPORT N 136192 10/1/2016INC C9744 ABD US W/CONTRAST 99291 CRITICAL CARE FIRST HOUR N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99292 CRITICAL CARE ADDL 30 MIN N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99304 NURSING FACILITY CARE INIT N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99305 NURSING FACILITY CARE INIT N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99306 NURSING FACILITY CARE INIT N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99307 NURSING FAC CARE SUBSEQ N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99308 NURSING FAC CARE SUBSEQ N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99309 NURSING FAC CARE SUBSEQ N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99310 NURSING FAC CARE SUBSEQ N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99315 NURSING FAC DISCHARGE DAY N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99316 NURSING FAC DISCHARGE DAY N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99318 ANNUAL NURSING FAC ASSESSMNT N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99460 INIT NB EM PER DAY HOSP N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99462 SBSQ NB EM PER DAY HOSP N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99463 SAME DAY NB DISCHARGE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99464 ATTENDANCE AT DELIVERY N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99465 NB RESUSCITATION N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99466 PED CRIT CARE TRANSPORT N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99467 PED CRIT CARE TRANSPORT ADDL N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99468 NEONATE CRIT CARE INITIAL N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99469 NEONATE CRIT CARE SUBSQ N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99471 PED CRITICAL CARE INITIAL N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99472 PED CRITICAL CARE SUBSQ N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99475 PED CRIT CARE AGE 2-5 INIT N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99476 PED CRIT CARE AGE 2-5 SUBSQ N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99477 INIT DAY HOSP NEONATE CARE N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99478 IC LBW INF < 1500 GM SUBSQ N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99479 IC LBW INF 1500-2500 G SUBSQ N X X 132256 11/1/2016



Rule Type

Denied Code


PaidCode


Rationale Code


INC C9744 ABD US W/CONTRAST 99480 IC INF PBW 2501-5000 G SUBSQ N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99481 #TOT BODY SYST HYPOTHERMIA N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99482 #SELECTIVE HEAD HYPOTHERMIA N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99485 SUPRV INTERFACILTY TRANSPORT N X 132256 11/1/2016INC C9744 ABD US W/CONTRAST 99486 SUPRV INTERFAC TRNSPORT ADDL N X 132256 11/1/2016INC C9744 ABD US W/CONTRAST G0406 INPT/TELE FOLLOW UP 15 N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST G0407 INPT/TELE FOLLOW UP 25 N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST G0408 INPT/TELE FOLLOW UP 35 N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST G0425 INPT/ED TELECONSULT30 N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST G0426 INPT/ED TELECONSULT50 N X X 132256 11/1/2016INC C9744 ABD US W/CONTRAST G0427 INPT/ED TELECONSULT70 N X X 132256 11/1/2016ME S0285 CNSLT BEFORE SCREEN COLONOSC 99481 #TOT BODY SYST HYPOTHERMIA N X X 128682 11/1/2016ME S0285 CNSLT BEFORE SCREEN COLONOSC 99482 #SELECTIVE HEAD HYPOTHERMIA N X X 128682 11/1/2016


McKesson Rationale Descriptions

Rationale Code McKesson Rationale Description

122368 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. The AMA designates this denied procedure as a "separate procedure". The "separate procedure" designation indicates that a certain procedure or service may be: a) Considered an integral component of another procedure/service, b) Performed independently, c) Unrelated or d) Distinct from other procedure(s)/service(s) provided at that time. Procedure codes designated as "separate procedures" may not be additionally reported when the procedure/service is performed as an integral component of another procedure/service. However, procedure codes designated as "separate procedures" should be additionally reported when performed independently, unrelated or distinct from other procedure(s)/service(s) provided. If the physician performs a designated "separate procedure" in addition to another procedure which is unrelated to the "separate procedure", modifier -59 should be appended to the designated "separate procedure" to indicate that the procedure was unrelated and that a distinct service was provided.

122446 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. When surgical supplies are submitted with a diagnostic or surgical procedure, only the primary service is recommended for reimbursement. This logic is supported by CMS, which assigns a status of "B" (Bundled Code) to this procedure, which is defined, "Payment for covered services are always bundled into payment for other services not specified. There will be no RVUs or payment amount for these codes and no separate payment is made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident." In addition, the CMS guideline for Standards of Medical/Surgical Practice found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I states, "Some examples of generic services integral to standard of medical/surgical services would include...Surgical supplies, unless excepted by existing CMS policy."

122618 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CMS assigns a status of "B" (Bundled Code) to the denied procedure, which is defined, "Payment for covered services are always bundled into payment for other services not specified. There will be no RVUs or payment amount for these codes and no separate payment is made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident."

122952 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. Placement of an intravenous needle or intracatheter, deemed necessary for administration of intravenous fluids and/or medication, is considered clinically integral to the performance of the primary procedure or service, and does not warrant separate reimbursement. This logic is supported by the CMS guideline for Medical/Surgical Package found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states, "Intravenous access... (e.g. CPT code 36000) is frequently necessary; therefore, CPT codes describing this service are not separately reported when performed in conjunction with" another more clinically intense procedure.

123492 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. Pulse oximetry represents an integral component of the usual monitoring services provided during a procedure. This logic is supported by the CMS guideline for Medical/Surgical Package found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states, "Most procedures require cardiopulmonary monitoring, either by the physician performing the procedure or an anesthesiologist/certified registered nurse anesthetist. Because these services are integral and routine, they are not to be separately reported. This may include cardiac monitoring, intermittent EKG procurement, oximetry or ventilation management. These services, when integral to the monitoring service, are not to be separately reported."

123530 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. Pulse oximetry represents an integral component of the usual monitoring services provided during a procedure. This logic is supported by the CMS guideline for Medical/Surgical Package found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states, "Most procedures require cardiopulmonary monitoring, either by the physician performing the procedure or an anesthesiologist/certified registered nurse anesthetist. Because these services are integral and routine, they are not to be separately reported. This may include cardiac monitoring, intermittent EKG procurement, oximetry or ventilation management. These services, when integral to the monitoring service, are not to be separately reported." CMS assigns a status of "T" to this procedure, which is defined, "There are RVUS and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made."

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123784 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. The provision of supplies is considered an integral component of the performance of the majority of diagnostic, surgical and therapeutic procedures. This logic is supported by CMS, which assigns a status of "B" (Bundled Code) to this procedure, which is defined, "Payment for covered services are always bundled into payment for other services not specified. There will be no RVUs or payment amount for these codes and no separate payment is made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident." In addition, the CMS guideline for Standards of Medical/Surgical Practice found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I states, "Some examples of generic services integral to standard of medical/surgical services would include...Surgical supplies, unless excepted by existing CMS policy." RVU determinations for surgical procedures include component values for physician work, practice expense and malpractice expense. As published in the Federal Register by CMS, 'practice expense' component includes the cost of supplies. Supplies that are routinely used in a typical clinical or surgical encounter are therefore included within the practice expense component and are not reported separately. According to CPT Surgical Guidelines- "Supplies and material provided by the physician (eg, sterile trays/drugs), over and above those usually included with the procedure(s) rendered are reported separately".

123886 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. The provision of supplies is considered an integral component of the performance of the majority of diagnostic, surgical and therapeutic procedures. This logic is supported by CMS, which assigns a status of "P" (Bundled/Excluded Codes) to this procedure, which is defined, "There are no RVUs and no payment amounts for these services. No separate payment should be made for them under the fee schedule. If the item or service is covered as incident to a physician service, payment for it is bundled into the payment for the physician service to which it is incident. If the item or service is covered as other than incident to a physician service, it is excluded from the fee schedule and should be paid under the other payment provision of the Act. " In addition, the CMS guideline for Standards of Medical/Surgical Practice found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I states, "Some examples of generic services integral to standard of medical/surgical services would include...Surgical supplies, unless excepted by existing CMS policy." RVU determinations for surgical procedures include component values for physician work, practice expense and malpractice expense. As published in the Federal Register by CMS, 'practice expense' component includes the cost of supplies. Supplies that are routinely used in a typical clinical or surgical encounter are therefore included within the practice expense component and are not reported separately. According to CPT Surgical Guidelines- "Supplies and material provided by the physician (eg, sterile trays/drugs), over and above those usually included with the procedure(s) rendered are reported separately".

124222 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CMS assigns a status of "P" (Bundled/Excluded Code) to the denied procedure in this scenario, which is defined, "There are no RVUs and no payment amounts for these services. No separate payment should be made for them under the fee schedule." If the item or service is covered as incident to a physician service, payment for it is bundled into the payment for the physician service to which it is incident. If the item or service is covered as other than incident to a physician service, it is excluded from the fee schedule and should be paid under the other payment provision of the Act. "

124349 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. The analysis of clinical data stored in a computer is considered integral to the performance of the primary diagnostic or therapeutic procedure. This logic is supported by CMS, which assigns a status of "B" (Bundled Code) to this procedure, which is defined, "Payment for covered services are always bundled into payment for other services not specified. There will be no RVUs or payment amount for these codes and no separate payment is made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident."

124472 Typically only one evaluation and management (E/M) procedure should be reported per date of service. When multiple E/M services are reported on the same date of service, only the most clinically intense E/M service will be recommended for reimbursement. This auditing logic is consistent with CMS guidelines from the Medicare Claims Processing Manual, Chapter 12, section 30.6.5 that states "If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level." According to CPT, a significant separately identifiable evaluation and management service, by the same physician on the same day of the procedure or other service may be reported by appending modifier -25.

124792 Edits exist between CPT and HCPCS Level II codes representing the same procedure or service. Reimbursement is typically recommended for the procedure code that has the more specific description. This logic is based on the CMS guideline which states '...when the narratives are not identical (e.g., the CPT code narrative is generic, whereas the HCPCS Level II code is specific) the Level II code should be used.'

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125787 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. RVU determinations for radiology procedures include component values for physician work, practice expense and malpractice expense. As published in the Federal Register by CMS, 'practice expense' component includes the cost of supplies. Supplies that are routinely used in a typical radiology encounter (e.g. syringes, alcohol wipes, swabs etc) are therefore included within the practice expense component and are not reported separately.

125788 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. The provision of supplies is considered an integral component of the performance of the majority of diagnostic, surgical and therapeutic procedures. This logic is supported by the CMS guideline for Standards of Medical/Surgical Practice found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states, "Some examples of generic services integral to standard of medical/surgical services would include:...Surgical supplies, unless excepted by existing CMS policy." RVU determinations for procedures include component values for physician work, practice expense and malpractice expense. As published in the Federal Register by CMS, 'practice expense' component includes the cost of supplies. Supplies that are routinely used in a typical clinical or surgical encounter are therefore included within the practice expense component and are not reported separately. According to CPT Medicine Guidelines - "Supplies and material provided by the physician (eg, sterile trays/drugs), over and above those usually included with the procedure(s) rendered are reported separately."

126121 A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that differ in technique or approach but lead to the same outcome represent overlap of service and duplication of effort, and are considered mutually exclusive. This logic is supported by the CMS guideline for Mutually Exclusive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states: "There are numerous procedure codes that are not to be reported together because they are mutually exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session." Edits exist between CPT and HCPCS Level II codes representing the same procedure or service. Reimbursement is typically recommended for the procedure code that has the more specific description. This logic is based on the CMS guideline which states '...when the narratives are not identical (e.g., the CPT code narrative is generic, whereas the HCPCS Level II code is specific) the Level II code should be used.'

127135 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. When surgical supplies are submitted with a diagnostic or surgical procedure, only the primary service is recommended for reimbursement. This logic is supported by CMS, which assigns a status of "X" (Statutory Exclusion) to this procedure, which is defined, "These codes represent an item or service that is not in the statutory definition of 'physician services' for fee schedule payment purposes. No RVUs or payment amounts are shown for these codes for these codes and no payment may be made under the physician fee schedule".

127215 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. The CMS guideline for venipuncture with drug administration in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter XI states "Because the placement of peripheral vascular access devices is integral to vascular (intravenous, intra-arterial) infusions and injections, the CPT codes for placement of these devices are not to be separately reported. Accordingly, insertion of an intravenous catheter (e.g., CPT codes 36000, 36410) for intravenous infusion, injection or chemotherapy administration (e.g., HCPCS/CPT codes 90760-90767, 90774-90775, C8950-C8952, 96409-96415, 96417, and C8953-C8955) should not be reported separately".

127432 Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive. Mutually exclusive edits exist between CPT and HCPCS Level II codes having similar or identical narratives. Reimbursement is typically recommended for the CPT code. This logic is based on the CMS guideline which states, "When both a CPT and a HCPCS Level II code have virtually identical narratives for a procedure or service, the CPT procedure code should be used."

127505 Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive. Typically only one evaluation and management (E/M) procedure should be reported per date of service. When multiple E/M services are reported on the same date of service, only the most clinically intense E/M service will be recommended for reimbursement. This auditing logic is consistent with CMS guidelines from the Medicare Claims Processing Manual, Chapter 12, section 30.6.5 that states "If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level." According to CPT, a significant separately identifiable evaluation and management service, by the same physician on the same day of the procedure or other service may be reported by appending modifier -25.

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128682 A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that differ in technique or approach but lead to the same outcome represent overlap of service and duplication of effort, and are considered mutually exclusive. This logic is supported by the CMS guideline for Mutually Exclusive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states: "There are numerous procedure codes that are not to be reported together because they are mutually exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session." Typically only one evaluation and management (E/M) procedure should be reported per date of service. When multiple E/M services are reported on the same date of service, only the most clinically intense E/M service will be recommended for reimbursement. This auditing logic is consistent with CMS guidelines from the Medicare Claims Processing Manual, Chapter 12, section 30.6.5 that states "If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level." According to CPT, a significant separately identifiable evaluation and management service, by the same physician on the same day of the procedure or other service may be reported by appending modifier -25.

128762 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CPT Guidelines state: "Evaluation and Management services codes should not be reported on the same day as 96020."

128825 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. According to the Level II HCPCS code descriptor, patient counseling and office visits are included in the services provided for comprehensive procedure S0199.

129170 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. The provision of supplies is considered an integral component of the performance of the majority of diagnostic, surgical and therapeutic procedures. This logic is supported by the CMS guideline for Standards of Medical/Surgical Practice found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states, "Some examples of generic services integral to standard of medical/surgical services would include:...Surgical supplies, unless excepted by existing CMS policy." RVU determinations for procedures include component values for physician work, practice expense and malpractice expense. As published in the Federal Register by CMS, 'practice expense' component includes the cost of supplies. Supplies that are routinely used in a typical clinical or surgical encounter are therefore included within the practice expense component and are not reported separately. According to CPT Medicine Guidelines - "Supplies and material provided by the physician (eg, sterile trays/drugs), over and above those usually included with the procedure(s) rendered are reported separately." Additionally, CPT guidelines for Hydration Therapeutic, Prophylactic, and Diagnostic Injections and Infusions states "If performed to facilitate the infusion or injection, the following services are included and are not separately reported:...e) Standard tubing, syringes, and supplies..."

129174 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. The provision of supplies is considered an integral component of the performance of the majority of diagnostic, surgical and therapeutic procedures. This logic is supported by the CMS guideline for Standards of Medical/Surgical Practice found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states, "Some examples of generic services integral to standard of medical/surgical services would include:...Surgical supplies, unless excepted by existing CMS policy." RVU determinations for procedures include component values for physician work, practice expense and malpractice expense. As published in the Federal Register by CMS, 'practice expense' component includes the cost of supplies. Supplies that are routinely used in a typical clinical or surgical encounter are therefore included within the practice expense component and are not reported separately. According to CPT Medicine Guidelines - "Supplies and material provided by the physician (eg, sterile trays/drugs), over and above those usually included with the procedure(s) rendered are reported separately." Additionally, CPT guidelines for Hydration Therapeutic, Prophylactic, and Diagnostic Injections and Infusions states "If performed to facilitate the infusion or injection, the following services are included and are not separately reported:...e). Standard tubing, syringes, and supplies..."

129445 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CMS assigns a status of "B" (Bundled Code) to the denied procedure, which is defined, "Payment for covered services are always bundled into payment for other services not specified. There will be no RVUs or payment amount for these codes and no separate payment is made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident." Analysis or review of information derived from cardiopulmonary monitoring is considered an inherent component of the majority of anesthesia, surgical, medical and evaluation and management services. It should be noted that code 93770 refers to the "reading" of the central venous pressure values registered on the manometer or transducer. The actual insertion and placement of a central venous line or catheter is typically a separately reportable service.

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129600 Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive. Telephone services represent non-face-to-face E&M physician services to an established patient, parent, or guardian on the telephone. CPT guidelines indicate that telephone services should not be reported "if the telephone service ends with a decision to see the patient within the next 24 hours or next available appointment," or if the "telephone call refers to an E/M service performed and reported by the physician within the previous seven days..."

129620 Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive. An on-line medical evaluation service represents a non-face-to-face E&M physician service to an established patient, parent, guardian, or health care provider via the Internet. CPT guidelines indicate that "if the on-line medical evaluation refers to an E/M service performed and reported by the physician within the previous seven days (either physician requested or unsolicited patient follow-up) or within the postoperative period of a previously completed procedure, then the service(s) are considered covered by the previous E/M service or procedure."

130900 A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that differ in technique or approach but lead to the same outcome represent overlap of service and duplication of effort, and are considered mutually exclusive. This logic is supported by the CMS guideline for Mutually Exclusive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states: "There are numerous procedure codes that are not to be reported together because they are mutually exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session." Per guidelines given in CMS' NCCI Policy Manual, Chapter XII "HCPCS code G0102 (Prostate cancer screening; digital rectal examination) is not separately payable with an evaluation and management code...In those instances when it is furnished on the same day as a covered E/M service, we believe it is appropriate to bundle it into the payment for the covered E/M encounter".

130986 A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that differ in technique or approach but lead to the same outcome represent overlap of service and duplication of effort, and are considered mutually exclusive. This logic is supported by the CMS guideline for Mutually Exclusive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states: "There are numerous procedure codes that are not to be reported together because they are mutually exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session." Per guidelines given in CMS' NCCI Policy Manual, Chapter XII "If a Medicare covered E&M service requires breast and pelvic examination, HCPCS code G0101 should not be additionally reported. However, if the Medicare covered E&M service and the screening services, G0101, are unrelated to one another, both HCPCS code G0101 and the E&M service may be reported appending modifier -25 to the E&M service CPT code. Use of modifier -25 indicates that the E&M service is significant and separately identifiable from the screening service, G0101". According to CPT, a significant separately identifiable evaluation and management service, by the same physician on the same day of the procedure or other service may be reported by appending modifier -25.

131794 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. Parenteral administration of fluid and drugs are considered clinically integral to the primary imaging study, and does not warrant separate reimbursement. This logic is supported by the CMS guideline for Interventional/Invasive Diagnostic Imaging found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter IX, which indicates that contrast administration services are integral to the primary procedure and not separately reportable.

132256 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. A provider's interpretation of radiology exams and studies, when performed for an inpatient or facility based outpatient, represents an integral part of a global service rendered under the provider's E&M service. E&M codes are structured to determine the complexity of the case and the time involved in the evaluation and management of the patient. CPT instructions for E&M codes state that medical decision making includes "the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed." According to the AMA, E&M codes also include the review of test results performed by other providers. This logic is supported by guidelines given in the CMS Medicare Claims Processing Manual, Chapter 13 - Radiology Services and Other Diagnostic Procedures, Section 100.1, that states, "Carriers generally distinguish between an 'interpretation and report' of an x-ray or an EKG procedure and a 'review' of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service." The review of a radiology exam or study is already included in the evaluation and management (E/M) payment.

132269 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CPT parenthetical guidelines state: "Do not report 96523 if any other services are provided on the same day."

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133859 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CMS assigns a status of "T" to this procedure, which is defined, "There are RVUS and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made." The CPT parenthetical guideline states: "Do not report 36591 in conjunction with other services except a laboratory service."

133860 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CMS assigns a status of "T" to this procedure, which is defined, "There are RVUS and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made." The CPT parenthetical guideline states: "Do not report 36592 in conjunction with other services except a laboratory service."

134840 Typically only one evaluation and management (E/M) procedure should be reported per date of service. When multiple E/M services are reported on the same date of service, only the most clinically intense E/M service will be recommended for reimbursement. This auditing logic is consistent with CMS guidelines from the Medicare Claims Processing Manual, Chapter 12, section 30.6.5 that states "If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level." According to CPT, a significant separately identifiable evaluation and management service, by the same physician on the same day of the procedure or other service may be reported by appending modifier -25. CPT introductory guidelines for Interprofessional Telephone/Internet Consultations states "The patient for whom the interprofessional telephone/ Internet consultation is requested may be either a new patient to the consultant or an established patient with a new problem or an exacerbation of an existing problem. However, the consultant should not have seen the patient in a face-to-face encounter within the last 14 days. When the telephone/Internet consultation leads to an immediate transfer of care or other face-to-face service (eg, a surgery, a hospital visit, or a scheduled office evaluation of the patient) within the next 14 days or next available appointment date of the consultant, these codes are not reported".

135310 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. Intraoperative neurophysiological monitoring is utilized during the performance of surgical procedures in order to assure that the nervous system has not been compromised or damaged during the primary surgical procedure. Per the May 2013 CPT Assistant, "Codes 95940 and 95941 describe continuous neurophysiologic monitoring, testing, and data interpretation distinct from the performance of specific type(s) of baseline neurophysiologic studies performed during surgical procedures. When the monitoring service is performed by the operating surgeon or anesthesiologist, the professional services are included in the surgeon's or anesthesiologist's primary service codes for the procedure and should not be reported separately." In addition, CPT guidelines direct the use of add-on procedures 95940 and 95941 in conjunction with multiple methods of baseline neurophysiologic testing, e.g. 92585. Most carriers only reimburse nerve monitoring procedures when they are performed as a diagnostic service. This logic is also supported by the CMS guideline for Standard of Medical/Surgical Practice found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states, "Examples of services integral to a large number of procedures include: isolation of structures limiting access to the surgical field such as bone, blood vessels, nerve, and muscles including stimulation for identification or monitoring."

136192 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. "Health Plan Policy (HPP)" edits are sourced to a specific benefit, medical or payment policy. Health Plans concur that these edits are consistent with current health plan policies. According to the CPT guidelines for selecting a level of E&M service, a variety of factors determine the complexity of decision making. These include the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed as an inherent component of the E/M service. Typically, an emergency room physician does not prepare the official written radiology interpretation and report. Rather, this is the responsibility of the radiologist reviewing the imaging study. Thus, reimbursement is recommended only for the formal interpretation and report, which is most commonly completed by the reviewing radiologist. In the uncommon scenario in which the formal radiology interpretation and report is performed by the emergency room physician only, reimbursement is recommended in accordance with individual health plan policy.

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136864 A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that differ in technique or approach but lead to the same outcome represent overlap of service and duplication of effort, and are considered mutually exclusive. This logic is supported by the CMS guideline for Mutually Exclusive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states: "There are numerous procedure codes that are not to be reported together because they are mutually exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session." Procedures that represent overlapping services are considered mutually exclusive. Both procedures 95924 and 93660 utilize the same type of equipment for evaluation of either cardiac or neurological response to a stimulus. Thus, when performed during the same session the reporting of procedure 95924 in addition to procedure 93660 results in significant overlap of service and duplication of effort.

136865 A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that differ in technique or approach but lead to the same outcome represent overlap of service and duplication of effort, and are considered mutually exclusive. This logic is supported by the CMS guideline for Mutually Exclusive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states: "There are numerous procedure codes that are not to be reported together because they are mutually exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session." Procedures that represent overlapping services are considered mutually exclusive. Both procedures 95943 and 93660 utilize the same type of equipment for evaluation of either cardiac or neurological response to a stimulus. Thus, when performed during the same session the reporting of procedure 95943 in addition to procedure 93660 results in significant overlap of service and duplication of effort.

136866 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. An assumption of same anatomic site is made during the auditing process. Due to previous treatment, if foreign materials such as nails, rods, or screws were implanted, their removal may be required during a current primary surgical intervention. Also, the implanted wires, pins, screws, or rods located in the operative site may now be causing pain or infection. Thus, removal of previously implanted devices/materials is clinically integral to the successful outcome of the primary procedure and do not warrant separate reimbursement. This logic is supported by the CMS guideline for Fractures found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter IV that states, "There are CPT codes (20670 and 20680) for removal of internal fixation devices (e.g., pin, rod). These codes are not separately reportable if the removal is performed as a necessary integral component of another procedure. For example, if revision of an open fracture repair for nonunion or malunion of bone requires removal of a previously inserted pin, CPT code 20670 or 20680 is not separately reportable."

136867 Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive. CPT codes include verbiage such as simple/complex, limited/complete, superficial/deep, partial/total in several of their procedure descriptions. When similar or identical procedures are performed, but are qualified by an increased level of complexity, only the definitive, or most comprehensive, service performed should be reported. This logic is supported by the CMS guideline for More Extensive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states, "...the less extensive procedure is included in the more extensive procedure." Typically only one evaluation and management (E/M) procedure should be reported per date of service. When multiple E/M services are reported on the same date of service, only the most clinically intense E/M service will be recommended for reimbursement. This auditing logic is consistent with CMS guidelines from the Medicare Claims Processing Manual, Chapter 12, section 30.6.5 that states "If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level." According to CPT, a significant separately identifiable evaluation and management service, by the same physician on the same day of the procedure or other service may be reported by appending modifier -25

136868 Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive. CPT guidelines for Preventive Medicine Services state, "Codes 99381-99397 include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventative medicine examination. (Refer to codes 99401, 99402, 99403, 99404, 99411 and 99412 for reporting those counseling/anticipatory guidance/risk factor reduction interventions that are provided at an encounter separate from the preventative medicine examination.)"

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136869 Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive. CPT guidelines for Preventive Medicine Services state, "Codes 99381-99397 include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventative medicine examination. (Refer to codes 99401, 99402, 99403, 99404, 99411 and 99412 for reporting those counseling/anticipatory guidance/risk factor reduction interventions that are provided at an encounter separate from the preventative medicine examination.)" When the descriptions of CPT and HCPCS Level II codes are similar, guidelines used to create relationships between CPT procedures are also applied to create the same relationship(s) with the comparable HCPCS Level II procedures.

136870 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. An assumption of same anatomic site is made during the auditing process. Debridement is considered an integral part of surgical site preparation that is necessary for the success of the primary procedure and thus, does not warrant separate reimbursement. This logic is supported by the CMS guideline for Standards of Medical/Surgical Practice found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states, "Examples of services integral to a large number of procedures include:...debridement of traumatized tissue..." In addition, CMS Integumentary System guidelines in Chapter III state, "If lesion removal, incision, or repair requires debridement of non-viable tissue surrounding a lesion, incision, or injury in order to complete the procedure, the debridement is not separately reportable."

136871 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. The AMA designates this denied procedure as a "separate procedure". The "separate procedure" designation indicates that a certain procedure or service may be: a) Considered an integral component of another procedure/service, b) Performed independently, c) Unrelated or d) Distinct from other procedure(s)/service(s) provided at that time. Procedure codes designated as "separate procedures" may not be additionally reported when the procedure/service is performed as an integral component of another procedure/service. However, procedure codes designated as "separate procedures" should be additionally reported when performed independently, unrelated or distinct from other procedure(s)/service(s) provided. If the physician performs a designated "separate procedure" in addition to another procedure which is unrelated to the "separate procedure", modifier -59 should be appended to the designated "separate procedure" to indicate that the procedure was unrelated and that a distinct service was provided. Procedure 33210 is incidental to many cardiac procedures in which interruption of the normal cardiac rhythm is anticipated. The placement of temporary pacemaker leads during percutaneous coronary intervention is rare; however, if clinically indicated, it is considered an integral part of the primary procedure, and as such does not warrant separate reimbursement.

136872 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CPT Assistant, April 2015, Frequently Asked Questions includes the following. "Acquiring CT images, as described by code 77014, is included in radiation oncology simulation codes 77280-77290, when performed on the same date of service. The CT service represents an integral part of this procedure and is not reported separately. The inclusion of CT guidance is described in the Radiation Oncology guidelines on page 435 of the CPT 2015 Professional, which states, "Simulation is the process of defining relevant normal and abnormal target anatomy, and acquiring the images and data necessary to develop the optimal radiation treatment process for the patient."

136873 A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that differ in technique or approach but lead to the same outcome represent overlap of service and duplication of effort, and are considered mutually exclusive. This logic is supported by the CMS guideline for Mutually Exclusive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states: "There are numerous procedure codes that are not to be reported together because they are mutually exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session." In a mutually exclusive relationship, the procedure with the higher RVU is typically recommended for reimbursement. Because RVUs provide a general measure of relative clinical intensity, the clinically more comprehensive procedures are typically assigned the higher values. When a mutually exclusive edit exists between a procedure with an assigned RVU and a procedure without an assigned RVU, reimbursement for the procedure with the assigned RVU is recommended. An assumption of same anatomic site is made during the auditing process. Site specific modifiers may be used to denote the performance of these procedures at different anatomic sites. CPT guidelines state, "If a more specific site descriptor than soft tissue is applicable (eg, breast), use the site specific codes for marker placement at that site."

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136874 A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that differ in technique or approach but lead to the same outcome represent overlap of service and duplication of effort, and are considered mutually exclusive. This logic is supported by the CMS guideline for Mutually Exclusive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states: "There are numerous procedure codes that are not to be reported together because they are mutually exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session." An assumption of same anatomic site is made during the auditing process. CPT guidelines associated with diagnostic ultrasound state: "Ultrasound guidance procedures also require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized. Use of ultrasound, without thorough evaluation of organ(s), or anatomic region, image documentation, and final, written report, is not separately reportable." A diagnostic ultrasound and ultrasonic guidance for needle placement are typically performed for separate indications independent of each other. However, when reported with the same date of service, an assumption is made in the auditing logic that both procedures involve the same session and same anatomic site. Based on the CPT coding language above, an ultrasonic guidance procedure is understood to include imaging protocols comparable to the limited diagnostic ultrasound; therefore when a guidance procedure and comparable limited diagnostic ultrasound are reported with the same date of service, reimbursement for both procedures is not recommended. In the clinical circumstance where documentation and appropriate modifiers properly support distinct and separate anatomic sites, and/or distinct clinical indications for each study additional reimbursement may be warranted

136878 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CMS guidelines for Drug Testing found in the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter X state,"Providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed. The Internet-only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 16 (Laboratory Services), Section 10 (Background) indicates that a laboratory test is a covered benefit only if the test result is utilized for management of the beneficiary's specific medical problem. Testing to confirm that a urine specimen is unadulterated is an internal control process that is not separately reportable." In addition, the description of the HCPCS drug testing codes includes the following, "includes sample validation when performed".

136879 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CMS guidelines for Drug Testing found in the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter X state,"Providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed. The Internet-only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 16 (Laboratory Services), Section 10 (Background) indicates that a laboratory test is a covered benefit only if the test result is utilized for management of the beneficiary's specific medical problem. Testing to confirm that a urine specimen is unadulterated is an internal control process that is not separately reportable."

136880 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. Anesthesia is considered separate and distinct when administered by an anesthesiologist or a nurse anesthetist; however, anesthesia is considered part of the global service when administered by the physician performing the primary procedure or service. This logic is supported by the CMS guideline for Medical/Surgical Package found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states, "When anesthesia is provided by the physician performing the primary service, the anesthesia services are included in the primary procedure

136881 Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive. According to CMS Medicare Benefit Policy Manual Chapter 13, Section 40.3 "encounters with more than one RHC (Rural Health Clinic) or FQHC (Federally Qualified Health Center) practitioner on the same day, or multiple encounters with the same RHC or FQHC practitioner on the same day constitute a single RHC or FQHC visit and is payable as one visit. This policy applies regardless of the length or complexity of the visit, the number or type of practitioners seen, whether the second visit is a scheduled or unscheduled appointment, or whether the first visit is related or unrelated to the subsequent visit."

136882 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CPT Assistant, July 2016, Frequently Asked Questions, includes the following, "When a physician performs color flow with a fetal umbilical artery Doppler, the color-flow mapping (93325) is included in the global service for code 76820, Doppler velocimetry, fetal; umbilical artery, when performed, and should not be reported separately."

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136883 Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive. CPT Assistant, April 2016, Frequently Asked Questions, includes the following, "CPT code 42950 should not be reported in addition to code 15757, when a free flap is used to reconstruct both a neck and tongue defect (after laryngectomy or glossectomy). The intraservice work of code 42950 is encompassed in code 15757, which includes harvesting a donor free flap, insetting the free flap at the recipient site using microsurgical technique, and closure of both donor and recipient sites. The pharyngeal reconstruction should be included in code 15757, as it would for wherever the flap was inserted."

136884 A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that differ in technique or approach but lead to the same outcome represent overlap of service and duplication of effort, and are considered mutually exclusive. This logic is supported by the CMS guideline for Mutually Exclusive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states: "There are numerous procedure codes that are not to be reported together because they are mutually exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session." CPT Assistant, May 2016, Inpatient Neonatal and Pediatric Critical Care Guidelines, includes the following, "No individual may report remote real-time video-conferenced critical care (0188T, 0189T) on the same calendar day when inpatient neonatal and pediatric critical care services (99468-99476) are reported."

136885 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CPT Assistant, May 2016, Frequently Asked Questions, includes the following, "It would not be appropriate to separately report joint manipulation under anesthesia in addition to the joint injection for arthrography procedures."

136886 A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that differ in technique or approach but lead to the same outcome represent overlap of service and duplication of effort, and are considered mutually exclusive. This logic is supported by the CMS guideline for Mutually Exclusive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states: "There are numerous procedure codes that are not to be reported together because they are mutually exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session." HCPCS code G0498 includes the initiation of infusion in the office/other outpatient setting as well as the follow up office/other outpatient visit at the conclusion of the infusion.

136887 A mutually exclusive relationship involves procedures that would not reasonably be performed during the same session. For example, combinations of procedures that represent contradictory services are considered mutually exclusive. This logic is supported by the CMS guideline for Mutually Exclusive Procedure found in the National Correct Coding Policy Manual for Part B Medicare Carriers, Chapter I that states "Mutually exclusive codes are those codes that cannot reasonably done in the same session. An example of a mutually exclusive situation is when the repair of the organ can be performed by two different methods. One repair method must be chosen to repair the organ and must be reported. A second example is the reporting of an "initial" service and a "subsequent" service. It is contradictory for a service to be classified as an initial and a subsequent service at the same time". CPT Assistant, February 2016 states, "A number of CPT codes cannot be reported when superficial radiation therapy is provided, including MeV treatment delivery codes (77402, 77407, 77412); clinical treatment planning codes (77261-77263); treatment device development codes (77332-77334); isodose planning codes (77306, 77307, 77316,-77318); radiation treatment management codes (77427, 77431, 77432, 77435, 77469, 77470, 77499); continuing medical physics consultation code (77336); and special physics consultation code (77370)."

136888 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CPT guidelines state, "Do not report 92015 in conjunction with 99173, 99174, 99177". In addition, CPT Assistant, March 2016, Frequently Asked Questions, states, "Code 92015 (refractive screening) is inherently included in codes 99174 and 99177 and should not be reported separately. Therefore, code 92015, Determination of refractive state, should not be reported in conjunction with codes 99174 and 99177."

136889 Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. CPT parenthetical guideline states: "Do not report 92015 in conjunction with 99173, 99174, 99177".

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McKesson Code Pair Expirations

Rule Type

Denied Code


Paid Code

Paid Code Description AAOS ACR ACS AMA

AMA RBRVS ASA CCI CCN CMS HPP

Horizon Expiration Date

ME 52277 CYSTOSCOPY AND TREATMENT 52649 PROSTATE LASER ENUCLEATION X 10/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54300 REVISION OF PENIS X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54304 REVISION OF PENIS X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54308 RECONSTRUCTION OF URETHRA X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54312 RECONSTRUCTION OF URETHRA X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54316 RECONSTRUCTION OF URETHRA X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54318 RECONSTRUCTION OF URETHRA X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54322 RECONSTRUCTION OF URETHRA X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54324 RECONSTRUCTION OF URETHRA X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54326 RECONSTRUCTION OF URETHRA X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54328 REVISE PENIS/URETHRA X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54332 REVISE PENIS/URETHRA X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54336 REVISE PENIS/URETHRA X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54340 SECONDARY URETHRAL SURGERY X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54344 SECONDARY URETHRAL SURGERY X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54348 SECONDARY URETHRAL SURGERY X 12/31/2016INC 54161 CIRCUM 28 DAYS OR OLDER 54352 RECONSTRUCT URETHRA/PENIS X 12/31/2016INC 99173 VISUAL ACUITY SCREEN 92015 DETERMINE REFRACTIVE STATE X X 10/31/2016INC 99174 OCULAR INSTRUMNT SCREEN BIL 92015 DETERMINE REFRACTIVE STATE X X 10/31/2016INC 99177 OCULAR INSTRUMNT SCREEN BIL 92015 DETERMINE REFRACTIVE STATE X X 10/31/2016ULT_PARENT 99401 PREVENTIVE COUNSELING INDIV 99404 PREVENTIVE COUNSELING INDIV 12/31/2016ULT_PARENT 99402 PREVENTIVE COUNSELING INDIV 99404 PREVENTIVE COUNSELING INDIV 12/31/2016ULT_PARENT 99403 PREVENTIVE COUNSELING INDIV 99404 PREVENTIVE COUNSELING INDIV 12/31/2016ULT_PARENT 99411 PREVENTIVE COUNSELING GROUP 99412 PREVENTIVE COUNSELING GROUP 12/31/2016

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CCI v22.3 Additions

Denied Code


Paid Code

Paid Code Description

Modifier Override

CCI Policy

Horizon Edit Effective Date

0213T NJX PARAVERT W/US CER/THOR 0437T IMPLTJ SYNTH RNFCMT ABDL WAL 0 Misuse of column two code with column one code 11/01/20160213T NJX PARAVERT W/US CER/THOR 0438T TPRNL PLMT BIODEGRDABL MATRL 0 Misuse of column two code with column one code 11/01/20160213T NJX PARAVERT W/US CER/THOR 0440T ABLTJ PERC UXTR/PERPH NRV 0 Misuse of column two code with column one code 11/01/20160213T NJX PARAVERT W/US CER/THOR 0441T ABLTJ PERC LXTR/PERPH NRV 0 Misuse of column two code with column one code 11/01/20160213T NJX PARAVERT W/US CER/THOR 0442T ABLTJ PERC PLEX/TRNCL NRV 0 Misuse of column two code with column one code 11/01/20160213T NJX PARAVERT W/US CER/THOR 0444T 1ST PLMT DRUG ELUT OC INS 0 Misuse of column two code with column one code 11/01/20160213T NJX PARAVERT W/US CER/THOR 0445T SBSQT PLMT DRUG ELUT OC INS 0 Misuse of column two code with column one code 11/01/20160216T NJX PARAVERT W/US LUMB/SAC 0437T IMPLTJ SYNTH RNFCMT ABDL WAL 0 Misuse of column two code with column one code 11/01/20160216T NJX PARAVERT W/US LUMB/SAC 0438T TPRNL PLMT BIODEGRDABL MATRL 0 Misuse of column two code with column one code 11/01/20160216T NJX PARAVERT W/US LUMB/SAC 0440T ABLTJ PERC UXTR/PERPH NRV 0 Misuse of column two code with column one code 11/01/20160216T NJX PARAVERT W/US LUMB/SAC 0441T ABLTJ PERC LXTR/PERPH NRV 0 Misuse of column two code with column one code 11/01/20160216T NJX PARAVERT W/US LUMB/SAC 0442T ABLTJ PERC PLEX/TRNCL NRV 0 Misuse of column two code with column one code 11/01/20160216T NJX PARAVERT W/US LUMB/SAC 0444T 1ST PLMT DRUG ELUT OC INS 0 Misuse of column two code with column one code 11/01/20160216T NJX PARAVERT W/US LUMB/SAC 0445T SBSQT PLMT DRUG ELUT OC INS 0 Misuse of column two code with column one code 11/01/20160228T NJX TFRML EPRL W/US CER/THOR 0437T IMPLTJ SYNTH RNFCMT ABDL WAL 0 Misuse of column two code with column one code 11/01/20160228T NJX TFRML EPRL W/US CER/THOR 0438T TPRNL PLMT BIODEGRDABL MATRL 0 Misuse of column two code with column one code 11/01/20160228T NJX TFRML EPRL W/US CER/THOR 0440T ABLTJ PERC UXTR/PERPH NRV 0 Misuse of column two code with column one code 11/01/20160228T NJX TFRML EPRL W/US CER/THOR 0441T ABLTJ PERC LXTR/PERPH NRV 0 Misuse of column two code with column one code 11/01/20160228T NJX TFRML EPRL W/US CER/THOR 0442T ABLTJ PERC PLEX/TRNCL NRV 0 Misuse of column two code with column one code 11/01/20160228T NJX TFRML EPRL W/US CER/THOR 0444T 1ST PLMT DRUG ELUT OC INS 0 Misuse of column two code with column one code 11/01/20160228T NJX TFRML EPRL W/US CER/THOR 0445T SBSQT PLMT DRUG ELUT OC INS 0 Misuse of column two code with column one code 11/01/20160230T NJX TFRML EPRL W/US LUMB/SAC 0437T IMPLTJ SYNTH RNFCMT ABDL WAL 0 Misuse of column two code with column one code 11/01/20160230T NJX TFRML EPRL W/US LUMB/SAC 0438T TPRNL PLMT BIODEGRDABL MATRL 0 Misuse of column two code with column one code 11/01/2016023

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