NCCI.2010.CLM.02222010.doc

NATIONAL CORRECT CODING INITIATIVE’S (NCCI)

GENERAL CORRESPONDENCE LANGUAGE

AND

SECTION-SPECIFIC EXAMPLES

(FOR NCCI EDITS AND MEDICALLY UNLIKELY EDITS (MUE))

FINAL REVISION:

February 22, 2010

EFFECTIVE:

April 1, 2010

TABLE OF CONTENTS

Page

General Correspondence Language for NCCI Edits

Standard preparation/monitoring services

HCPCS/CPT procedure code definition

CPT Manual and CMS coding manual instructions

Mutually exclusive procedures

Sequential procedures

CPT “Separate procedure” definition

More extensive procedure

Gender-specific (formerly Designation of sex) procedures

Standards of medical/surgical practice

Anesthesia included in surgical procedures

Laboratory panels

Deleted/modified edits for NCCI

Misuse of column two code with column one code

General Correspondence Language for Medically Unlikely Edits (MUE) (Units of Service)

Medically Unlikely Edits (MUE) (Units of Service)

Deleted/modified edits for MUE

Section-specific examples for Anesthesia Services

(CPT codes 00000 - 09999)

NCCI edits 11-13

Medically Unlikely Edits (Units of Service)

Section-specific examples for Surgery: Integumentary System (CPT Codes 10000 - 19999)

NCCI edits

14-16

Medically Unlikely Edits (Units of Service)

Section-specific examples for Surgery: Musculoskeletal System (CPT Codes 20000 - 29999)

NCCI edits

17-19

Medically Unlikely Edits (Units of Service)

TABLE OF CONTENTS (Continued)

Section-specific examples for Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems (CPT Codes 30000 - 39999)

NCCI edits

20-22 Medically Unlikely Edits (Units of Service)

Section-specific examples for Surgery: Digestive System

(CPT Codes 40000 - 49999)

NCCI edits 23-25

Medically Unlikely Edits (Units of Service) Section-specific examples for Surgery: Urinary, Male Genital, Female Genital, Maternity Care and Delivery Systems (CPT Codes 50000 - 59999)

NCCI edits 26-28

Medically Unlikely Edits (Units of Service) Section-specific examples for Surgery: Endocrine, Nervous, Eye and Ocular Adnexa, Auditory Systems (CPT Codes 60000 - 69999)

29-31

Medically Unlikely Edits (Units of Service) Section-specific examples for Radiology Services (CPT Codes 70000 - 79999)

NCCI edits 32-34

Medically Unlikely Edits (Units of Service) Section-specific examples for Pathology and Laboratory Services (CPT Codes 80000 - 89999)

35-37

Medically Unlikely Edits (Units of Service) Section-specific examples for Medicine, Evaluation and Management Services (CPT Codes 90000 - 99999)

NCCI edits 38-40

Medically Unlikely Edits (Units of Service) TABLE OF CONTENTS (Continued)

Section-specific examples for Supplemental Services (HCPCS Level II Codes A0000 - V9999)

NCCI edits 41-43

Medically Unlikely Edits (Units of Service) Section-specific examples for CPT Category III Codes

(Temporary CPT Codes for Emerging Technology, Services, and Procedures) (CPT Codes 0000T – 0999T)

44-46

Medically Unlikely Edits (Units of Service) Examples of Deleted National Correct Coding Initiative (NCCI) Edits and Medically Unlikely Edits (MUE)

Deleted NCCI Edit Example

Deleted MUE Example 47 National Correct Coding Initiative’s

General Correspondence Language

1. Standard preparation/monitoring services: Anesthesia services require certain services to prepare a patient prior to the administration of anesthesia and to monitor a patient during the course of anesthesia. Additionally, when monitored anesthesia care (MAC) is provided, the attention devoted to patient monitoring is of a similar level of intensity so that general anesthesia may be established if needed. The specific services necessary to prepare and monitor a patient vary among procedures based upon the extent of the surgical procedure, the type of anesthesia (general, MAC, regional, local, etc.), and the surgical risk. The physician determines which preparation and monitoring services are utilized for an anesthesia procedure. These services are included in the anesthesia service. Accordingly, when reporting the anesthesia service code, HCPCS/CPT code_____ (the column one HCPCS/CPT code), the services described by HCPCS/CPT code ______ (the column two HCPCS/CPT code) are included in the anesthesia service.

2. HCPCS/CPT procedure code definition: The HCPCS/CPT procedure code definition, or descriptor, is based upon contemporary medical practice. When a HCPCS/CPT code is submitted to Medicare, all services described by the descriptor should have been performed. Because some HCPCS/CPT codes describe complex procedures with several components which may under certain circumstances be performed independently, some of the component procedures have their own HCPCS/CPT codes. If a HCPCS/CPT code is reported along with other HCPCS/CPT codes that are components of the descriptor of the first code, only the first code should be reported. The HCPCS/CPT code ______ (the column one HCPCS/CPT code) descriptor includes the service described by the descriptor of HCPCS/CPT code _____ (the column two HCPCS/CPT code). Thus, based upon the HCPCS/CPT code descriptors, ______ (the column two HCPCS/CPT code) is bundled into______ (the column one HCPCS/CPT code).

3. CPT Manual and CMS coding manual instructions: In addition to CPT procedure code definitions or descriptors, instructions in the CPT Manual are provided either as an introduction to CPT sections or parenthetically. Additionally CMS issues coding instructions and guidelines in its manuals, program memoranda, and other publications. In the case of HCPCS/CPT code____ (the column one HCPCS/CPT code) and HCPCS/CPT code_____ (the column two HCPCS/CPT code), CPT or CMS instructions identify appropriate methodology for code submission and accordingly, HCPCS/CPT code ______ (the column two HCPCS/CPT code) is included in or cannot be reported with HCPCS/CPT code _____ (the column one HCPCS/CPT code).

4. Mutually exclusive procedures: In order to provide a sufficiently broad listing of descriptive terms and identifying HCPCS/CPT codes, certain services or procedures are listed which would not reasonably be performed at the same session by the same provider on the same beneficiary. In the case of HCPCS/CPT code______(the column one HCPCS/CPT code) and HCPCS/CPT code _____(the column two HCPCS/CPT code), it would be unreasonable to expect these services to be performed at a single patient encounter and, therefore, these HCPCS/CPT codes have been paired together as edits.

5. Sequential procedures: If a provider attempts several procedures in direct succession at a patient encounter to accomplish the same end, only the procedure that successfully accomplishes the expected result is reported. Generally, this occurs when a less extensive procedure fails and requires the performance of a more extensive procedure. A failed procedure followed by a more extensive procedure should not be reported separately. Procedures that are often performed in sequence have been identified and the less extensive procedure is not separately reportable with the more extensive procedure. When the procedures corresponding to HCPCS/CPT code____ (the column one HCPCS/CPT code) and HCPCS/CPT code _____ (the column two HCPCS/CPT code) are performed in sequence at the same patient encounter, only HCPCS/CPT code______ (the column one HCPCS/CPT code) may be reported.

6. CPT “Separate procedure” definition: The narrative for many HCPCS/CPT codes includes a parenthetical statement that the procedure represents a "separate procedure". The inclusion of this statement indicates that the procedure can be performed separately but should not be reported when a related service is performed. A “separate procedure” should not be reported when performed along with another procedure in an anatomically related region through the same skin incision or orifice, or surgical approach. HCPCS/CPT code____ (the column two HCPCS/CPT code) is designated as a "separate procedure". Therefore, if it is reported with HCPCS/CPT code______ (the column one HCPCS/CPT code), HCPCS/CPT code (the column two HCPCS/CPT code) is bundled into HCPCS/CPT code_____ (the column one HCPCS/CPT code).

7. More extensive procedure: Some procedures can be performed at varying levels of complexity. The HCPCS/CPT codes corresponding to more extensive procedures always include the HCPCS/CPT codes corresponding to less complex procedures. HCPCS/CPT code _______ (the column one HCPCS/CPT code) is a more extensive procedure that includes HCPCS/CPT code_______ (the column two HCPCS/CPT code). Accordingly, only the more extensive procedure, ______ (the column one HCPCS/CPT code) should be reported. HCPCS/CPT code_____ (the column two HCPCS/CPT code) is bundled into HCPCS/CPT code______ (the column one HCPCS/CPT code).

9. Gender-specific (formerly Designation of sex) procedures: The performance of certain procedures may require significantly different approaches when performed in a male as opposed to a female. Some HCPCS/CPT code descriptors designate these procedures by specifying if the service or procedure is to be reported for a male or a female or by anatomical description. HCPCS/CPT code combinations that are identical, except that one code describes a procedure for a female and the other describes a procedure for a male, cannot be reported for the same session, the same provider, and the same beneficiary. HCPCS/CPT codes _____ (the column one HCPCS/CPT code) and _____(the column two HCPCS/CPT code) represent such a combination and should not be reported together.

10. Standards of medical/surgical practice: Under Medicare, all services necessary to complete a procedure based upon standard medical/surgical practice are included in the procedure. Many procedures that are typically necessary to complete a more comprehensive procedure have been assigned independent HCPCS/CPT codes because they may be performed independently in other settings. The service described by HCPCS/CPT code ____ (the column two HCPCS/CPT code) is typically included when performing the procedure described by HCPCS/CPT code ____ (the column one HCPCS/CPT code) and is therefore bundled into HCPCS/CPT code _____(the column one HCPCS/CPT code.)

11. Anesthesia included in surgical procedures: Pursuant to Medicare’s Anesthesiology Rules, Medicare does not pay separately for anesthesia other than moderate conscious sedation under certain circumstances when provided by the same physician who performs the medical or surgical procedure requiring the anesthesia. HCPCS/CPT codes describing anesthesia services or services that are bundled into anesthesia services should not be reported in addition to the surgical procedure requiring the anesthesia services. Accordingly, HCPCS/CPT code ____ (the column two HCPCS/CPT code representing the anesthesia service or service bundled into anesthesia) is included in the surgical service described by HCPCS/CPT code____ (the column HCPCS/CPT code).

12. Laboratory panels: Laboratory panels, described in CPT as "Organ or Disease Oriented Panels,” define groupings of laboratory tests that are commonly performed together in clinical practice. When a HCPCS/CPT code describing a panel is reported, HCPCS/CPT codes identifying the individual tests included in the panel should not be reported separately. HCPCS/CPT code____ (the column one HCPCS/CPT code representing the laboratory panel) includes HCPCS/CPT code _____ (the column two HCPCS/CPT code). Therefore HCPCS/CPT code____ (the column two HCPCS/CPT code) is bundled into HCPCS/CPT code____ (the laboratory panel code or the column one HCPCS/CPT code.)

13. Deleted/modified edits for NCCI: National Correct Coding Initiative (NCCI) edits were developed based upon review of existing local and national edits, review of standards of medical care, review of CPT instructions and descriptors, review of provider billing patterns and Medicare policies. Comments about NCCI edits are received from the AMA and the national medical societies, representatives of the AMA’s CPT Editorial Panel, CPT Advisory, and Health Care Professionals Advisory (HCPAC) Committees, CMS Central and Regional Offices, Contractor Medical Directors, contractor staff, physicians, other providers, and independent billing consultants. Based upon input from these sources, NCCI edits are sometimes deleted. NCCI edits may also be deleted for other reasons such as CMS policies, modified HCPCS/CPT code descriptors or coding instructions, deletion of HCPCS/CPT codes, or modified medical practice. (Occasionally the order of the codes in an edit needs to be reversed. In such situations, the original edit is deleted and a new edit is added with the order of the codes reversed.) The HCPCS/CPT code pair edit, ______ (the column one HCPCS/CPT code) and ______ (the column two HCPCS/CPT code) was deleted from the NCCI for one of these reasons.

14. Misuse of column two code with column one code: HCPCS/CPT codes have been written as precisely as possible to not only describe a specific procedure but to also avoid describing similar procedures which are already defined by other HCPCS/CPT codes. When a HCPCS/CPT code is reported, the physician or non-physician provider must have performed all of the services noted in the descriptor unless the descriptor states otherwise. (Occasionally, a HCPCS/CPT code descriptor will identify certain services that may or may not be included.) A HCPCS/CPT code should not be reported out of the context for which it was intended. When the procedure described by HCPCS/CPT code _________ (the column two HCPCS/CPT code) is reported with the procedure described by HCPCS/CPT code _______ (the column one HCPCS/CPT code), reporting the former code represents a misuse of this code, and separate payment is not allowed.

15. Medically Unlikely Edits (MUE) (Units of Service): Most HCPCS/CPT codes describe procedures that may be reported a maximum number of times by a single provider for the same beneficiary on the same date of service. If a provider bills units of service for HCPCS/CPT codes in excess of established limits, the edits prevent payment. The Medically Unlikely Edit values are set based upon anatomic considerations, HCPCS/CPT code descriptors, HCPCS/CPT coding instructions, CMS policies, nature of analyte, nature of service/procedure, nature of equipment, and/or clinical judgment based on input from many sources. MUE values were reviewed by national healthcare organizations before implementation. All MUE values have been evaluated with 100% claims data from a six month period. CMS publishes most MUE values. However, unpublished MUE values are confidential information for CMS and CMS contractors’ use only. No information about unpublished MUE values shall be released or shared outside your organization.

16. Deleted/modified edits for MUE: Medically Unlikely Edits (MUE) were developed based upon anatomic considerations, HCPCS/CPT code descriptors, HCPCS/CPT coding instructions, CMS policies, nature of service/procedure, nature of analyte, nature of equipment, and/or clinical judgment. Prior to implementation most MUE were reviewed by national healthcare organizations. Comments about MUE are received from the AMA and the national medical societies, representatives of the AMA’s CPT Editorial Panel, CPT Advisory, and Health Care Professionals Advisory (HCPAC) Committees, CMS Central and Regional Offices, Medicare Contractor Medical Directors, contractor staff, physicians, other providers, and independent billing consultants. Based upon input from these sources, an MUE may be deleted. MUE may also be deleted for other reasons such as CMS policies, modified HCPCS/CPT code descriptors or coding instructions, deletion of HCPCS/CPT codes, or modified medical practice. (Occasionally an MUE is modified. In such situations the original MUE is deleted, and a new MUE with the revised MUE value is added). The MUE for the HCPCS/CPT code ______ was deleted or modified for one of these reasons.

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Anesthesia Services CPT Codes 00000-09999

Correspondence Language Policy/Example Number 1.00000 - Standard preparation/monitoring services

An example of a “standard preparation/monitoring service” integral to anesthesia services is the placement of an intravenous access line (CPT code 36000) prior to the administration of general anesthesia. This procedure is necessary to prepare the patient for a general anesthesia procedure and, therefore, is included as a part of the anesthesia service. CPT code 36000 is bundled into all anesthesia service codes.

Correspondence Language Policy/Example Number 2.00000 – HCPCS/CPT procedure code definition For example, the descriptor for CPT code 99143 “(Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; younger than 5 years of age, first 30 minutes intra-service time)” indicates that the code includes moderate conscious sedation services other than those services described by anesthesia codes (00100- 01999). Therefore, CPT code 99143 should not be separately reported with anesthesia codes such as CPT code 00100 “(Anesthesia for procedures on salivary glands, including biopsy)”.

Correspondence Language Policy/Example Number 3.00000 - CPT Manual and CMS coding manual instructions For example, in the CPT Manual instruction under anesthesia for diagnostic arteriography/venography (CPT code 01916), the reference note states: “(Do not report 01916 in conjunction with therapeutic codes 01924-01926, 01930-01933)”. Therefore, CPT code 01916 is bundled with CPT codes 01924-01926 and 01930-01933.

Correspondence Language Policy/Example Number 4.00000 - Mutually exclusive procedures

For example, a physician administering anesthesia for procedures on the heart with pump oxygenator (CPT code 00562) would not also report anesthesia for procedures on the heart, with pump oxygenator with hypothermic circulatory arrest (CPT code 00563) for the same patient encounter. Only one of these two types of anesthesia would be administered in a single patient encounter. Therefore, CPT codes 00562 and 00563 are mutually exclusive of each other.

Correspondence Language Policy/Example Number 7.00000 – More extensive procedure

For example, CPT code 01830 describes anesthesia for open or surgical arthroscopic/endoscopic procedures on the wrist as well as other sites contiguous to the wrist, and CPT code 01829 describes anesthesia for diagnostic arthroscopic procedures on the wrist. Reporting CPT code 01829 with CPT code 01830 is not appropriate because the procedure described by CPT code 01830 is more extensive than the procedure described by CPT code 01829. In this case CPT code 01829 is bundled into CPT code 01830.

Correspondence Language Policy/Example Number 9.00000 – Gender-specific (formerly Designation of sex) procedures For example, CPT code 00920 describes anesthesia for procedures on male genitalia including open urethral procedures, and CPT code 00942 describes anesthesia for vaginal procedures including open urethral procedures. The two CPT codes cannot be reported for the same beneficiary. Therefore only the appropriate CPT procedure code may be reported.

Correspondence Language Policy/Example Number 14.00000 - Misuse of column two code with column one code

For example, CPT code 95956 describes “Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours”. When EEG monitoring is performed during anesthesia for an intracranial procedure (CPT code 00210), reporting this monitoring separately with CPT code 95956 is a misuse of CPT code 95956. Intraoperative EEG monitoring is integral to anesthesia services for intracranial procedures. Therefore CPT code 95956 is not reported separately with CPT code 00210.

Correspondence Language Policy/Example Number 15.00000 – Medically Unlikely Edits (Units of Service)

For example, CPT code 01996 (“Daily hospital management of epidural or subarachnoid continuous drug administration”) by definition includes management of epidural or subarachnoid continuous drug administration for an entire day. This code may be reported with only one unit of service for a single date of services. If units of service in excess of one are reported, the MUE prevents payment.

Medically Unlikely Edits (Units of Service) do not apply to Anesthesia Services (CPT codes 00100-01995).

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Integumentary System CPT Codes 10000-19999

Correspondence Language Policy/Example Number 2.10000 – HCPCS/CPT procedure code definition For example, the code descriptor for CPT code 19302 is “Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy”, and the code descriptor for CPT code 19301 is “Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy);”. Therefore, based upon the code descriptors the procedure described by CPT code 19301 is a component of the procedure described by CPT code 19302, and CPT code 19301 is bundled into CPT code 19302.

Correspondence Language Policy/Example Number 3.10000 - CPT Manual and CMS coding manual instructions For example, the CPT Manual instruction under “Excision - Benign Lesions”, states that the excision includes simple closure. Therefore the procedure described by the column one CPT code 11400 (“Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 0.5 cm or less”) includes the procedure described by the column two CPT code 12001 (“Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5cm or less”). CPT code 12001 is bundled into CPT code 11400.

Correspondence Language Policy/Example Number 4.10000 - Mutually exclusive procedures For example, a physician performing a destruction of a malignant lesion of the arm by laser surgery, electrosurgery, cryosurgery, chemosurgery, or surgical curettement (CPT code 17260) would not also report an excision of the same malignant lesion of the arm (CPT code 11600). Only one method of treatment of the malignant skin lesion would be performed at a single patient encounter. Therefore, CPT codes 17260 and 11600 are mutually exclusive of each other.

Correspondence Language Policy/Example Number 5.10000 - Sequential procedures

For example, CPT code 10021 describes a fine needle aspiration biopsy without imaging guidance. CPT code 19101 describes an open incisional biopsy of the breast. If a fine needle aspiration biopsy of a breast lesion is unsuccessful and the physician sequentially performs an incisional biopsy of the same lesion at the same patient encounter, only the successful open incisional biopsy may be reported. Therefore, CPT code 10021 is not separately reportable with CPT code 19101.

Correspondence Language Policy/Example Number 6.10000 – CPT “separate procedure” definition For example, the code descriptor for CPT code 19100 (“Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)”) includes the “separate procedure” designation. When an excision of a breast lesion (CPT code 19125) is performed, the procedure described by CPT code 19100 is not a separate procedure when performed on the ipsilateral breast. Therefore, CPT code 19100 cannot be reported separately and is bundled into CPT code 19125.

Correspondence Language Policy/Example Number 7.10000 - More extensive procedure For example, CPT code 19307 describes a modified radical mastectomy which removes the entire breast and axillary adipose tissue. Although the primary purpose of a radical mastectomy is generally the treatment of a malignant lesion, other lesions in the breast such as cysts are also removed. Separate reporting of CPT code 19120 which describes excision of benign breast lesions such as cysts is not appropriate with CPT code 19307 for the same breast because the latter represents the more extensive procedure. In this example CPT code 19120 is bundled into CPT code 19307.

Correspondence Language Policy/Example Number 10.10000 - Standards of medical/surgical practice For example, simple avulsion of a nail plate (CPT code 11730) includes skin debridement (CPT code 11040) at the same site as a standard of medical /surgical practice. Therefore, CPT code 11040 is bundled into CPT code 11730.

Correspondence Language Policy/Example Number 11.10000 - Anesthesia included in surgical procedures For example, when an avulsion of a nail plate (CPT code 11730) is performed, anesthesia may be provided by the surgeon using a digital nerve block (CPT code 64450). Because this type of anesthesia provided by the surgeon performing the procedure is not separately payable, CPT code 64450 is bundled into CPT code 11730 when the same physician performs both procedures.

Correspondence Language Policy/Example Number 14.10000 - Misuse of column two code with column one code

For example, CPT code 11900 (Intralesional injection) describes a therapeutic cutaneous intralesional injection. It is a misuse of this code to report it for the injection of local anesthesia in order to perform another procedure such as an excision of a benign skin lesion (CPT code 11400). Therefore, CPT code 11900 is bundled into CPT code 11400.

Correspondence Language Policy/Example Number 15.10000 – Medically Unlikely Edits (Units of Service)

For example, CPT code 11719 (Trimming of nondystrophic nails, any number) by definition includes “any number” of nails. This code may be reported only once for a patient on any single date of service by the same provider. If units of service in excess of one are reported, the MUE prevents payment.

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Musculoskeletal System CPT Codes 20000-29999

Correspondence Language Policy/Example Number 2.20000 - HCPCS/CPT procedure code definition For example, the code descriptor for CPT code 21045 is “Excision of malignant tumor of mandible; radical resection”, and the code descriptor for CPT code 21044 is “Excision of malignant tumor of mandible;”. Therefore based upon the code descriptors the procedure described by CPT code 21044 is a component of the procedure described by CPT code 21045, and CPT code 21044 is bundled into CPT code 21045.

Correspondence Language Policy/Example Number 3.20000 - CPT Manual and CMS coding manual instructions For example, the parenthetical note following CPT code 29889 states: “(Procedures 29888 and 29889 should not be used with reconstruction procedures 27427-27429)”. Thus, CPT code 29889 is bundled into the more comprehensive procedures reported as CPT codes 27427, 27428, and 27429.

Correspondence Language Policy/Example Number 4.20000 - Mutually exclusive procedures For example, CPT codes 27441 and 27442 describe different types of knee arthroplasties of the tibial plateau. CPT code 27441 describes the procedure on the tibial plateau with debridement and partial synovectomy and CPT code 27442 describes the procedure on femoral condyles or the tibial plateau(s). Since both procedures would not be performed on the same knee at the same patient encounter, the two procedures are mutually exclusive of one another.

Correspondence Language Policy/Example Number 5.20000 - Sequential procedures For example, if an initial deep bone biopsy by needle or trocar (CPT code 20225) is unsuccessful and is followed by an open biopsy (CPT code 20250) at the same patient encounter, only CPT code 20250 may be reported. Therefore, CPT code 20225 is not separately reportable with CPT code 20250.

Correspondence Language Policy/Example Number 6.20000 – CPT “separate procedure” definition For example, the code descriptor for CPT code 29870 (“Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)”) includes the “separate procedure” designation. When a diagnostic arthroscopy of the knee with major synovectomy in two or more compartments (CPT code 29876) is performed, the procedure described by CPT code 29870 on the ipsilateral knee is not a separate procedure. Therefore, CPT code 29870 cannot be reported separately and is bundled into CPT code 29876.

Correspondence Language Policy/Example Number 7.20000 - More extensive procedure For example, CPT code 20005 describes incision of a deep soft tissue abscess. CPT code 20000 describes incision of a superficial soft tissue abscess. Since incision of a deep soft tissue abscess (CPT code 20005) is more extensive than incision of a superficial soft tissue abscess (CPT code 20000) when performed at the same anatomic site, CPT code 20000 is bundled into CPT code 20005.

Correspondence Language Policy/Example Number 10.20000 - Standards of medical/surgical practice

For example, CPT code 25115 describes a radical excision of a bursa or synovia of the wrist. It is standard surgical practice to preserve neurologic function by isolating and freeing nerves as necessary. A neuroplasty (e.g. CPT code 64719) should not be reported separately for this process. Therefore, CPT code 64719 is bundled into CPT code 25115.

Correspondence Language Policy/Example Number 11.20000 - Anesthesia included in surgical procedures

For example, when a small joint or bursa arthrocentesis, aspiration and/or injection (CPT code 20600) is performed, anesthesia may be provided by the surgeon using a digital nerve block (CPT code 64450). Because this type of anesthesia provided by the surgeon performing the procedure is not separately payable, CPT code 64450 is bundled into CPT code 20600 when the same physician performs both procedures.

Correspondence Language Policy/Example Number 14.20000 - Misuse of column two code with column one code For example, CPT code 20550 (“Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)”) describes a therapeutic musculoskeletal injection. It is a misuse of this code to report it for the injection of local anesthesia in order to perform another procedure such as a hallux valgus correction (CPT code 28292). Therefore, CPT code 20550 is bundled into CPT code 28292.

Correspondence Language Policy/Example Number 15.20000 – Medically Unlikely Edits (Units of Service)

For example, CPT code 27440 (Arthroplasty, knee, tibial plateau) may only be performed on a knee once on a single date of service. Since this procedure could be performed bilaterally on a patient on a single date of service, a maximum of two units of service is allowed for a single date of service. If units of service in excess of two are reported, the MUE prevents payment.

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Respiratory System, Cardiovascular System, Hemic and Lymphatic Systems, Mediastinum and Diaphragm CPT Codes 30000-39999

Correspondence Language Policy/Example Number 2.30000 - HCPCS/CPT procedure code definition For example, the code descriptor for CPT code 33612 is “Repair of double outlet right ventricle with intraventricular tunnel repair; with repair of right ventricular outflow tract obstruction” and the code descriptor for CPT code 33611 is “Repair of double outlet right ventricle with intraventricular tunnel repair;”. Therefore, based upon the code descriptors the procedure described by CPT code 33611 is a component of the procedure described by CPT code 33612, and CPT code 33611 is bundled into CPT code 33612.

Correspondence Language Policy/Example Number 3.30000 - CPT Manual and CMS coding manual instructions For example, CPT code 33645 describes a direct or patch closure of the sinus venosus with or without anomalous pulmonary venous drainage. The CPT Manual instruction below CPT code 33645 states: “(Do not report 33645 in conjunction with 33724, 33726)”. Therefore, CPT code 33724 which describes a repair of isolated partial anomalous pulmonary venous return may not be reported in addition to CPT code 33645.

Correspondence Language Policy/Example Number 4.30000 - Mutually exclusive procedures For example, CPT codes 33820 and 33822 describe different types of repairs of a patent ductus arteriosus. CPT code 33820 describes a patent ductus arteriosus repair by ligation, and CPT code 33822 describes a patent ductus arteriosus repair by division. Since both procedures would not be performed on a patent ductus arteriosus at the same patient encounter, the two procedures are mutually exclusive of one another.

Correspondence Language Policy/Example Number 5.30000 - Sequential procedures For example, if a percutaneous needle biopsy of the pleura (CPT code 32400) is unsuccessful and is followed at the same patient encounter by a thoracotomy to perform an open biopsy of the pleura (CPT code 32402), only CPT code 32402 may be reported. Therefore, CPT code 32400 is not separately reportable with CPT code 32402.

Correspondence Language Policy/Example Number 6.30000 – CPT “separate procedure” definition

For example, the code descriptor for CPT code 33210 (“Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure)”) includes the “separate procedure” designation. When a coronary artery bypass with single arterial graft procedure (CPT code 33533) is performed, the procedure described by CPT code 33210 is not a separate procedure. Therefore, CPT code 33210 cannot be reported separately and is bundled into CPT code 33533.

Correspondence Language Policy/Example Number 7.30000 - More extensive procedure For example, CPT code 32480 describes a thoracotomy with lobectomy of the lung which removes the entire lobe of a lung. Since thoracotomy with lung biopsy (CPT code 32095) removes a small portion of pulmonary tissue, the procedure described by CPT code 32480 is more extensive than the one described by CPT code 32095. Therefore, CPT code 32095 is bundled into CPT code 32480.

Correspondence Language Policy/Example Number 10.30000 - Standards of medical/surgical practice For example, CPT code 32480 describes a thoracotomy with removal of a single lobe of a lung. CPT code 32100 describes a major thoracotomy which is the surgical approach for the procedure described by CPT code 32480 and is the standard of medical/surgical practice. Therefore, CPT code 32100 is bundled into CPT code 32480.

Correspondence Language Policy/Example Number 11.30000 - Anesthesia included in surgical procedures For example, when direct operative laryngoscopy with foreign body removal is performed (CPT code 31530) and anesthesia is also performed by the surgeon (CPT code 00320), separate reporting for the anesthesia service is inappropriate. Therefore CPT code 00320 is bundled into CPT code 31530.

Correspondence Language Policy/Example Number 14.30000 - Misuse of column two code with column one code For example, CPT code 35226 (“Repair blood vessel, direct; lower extremity”) describes an open blood vessel repair of the lower extremity. It is a misuse of CPT code 35226 to report it for the repair of the site where a percutaneous intra-aortic balloon assist device is removed (CPT code 33968). Therefore CPT code 35226 is bundled into CPT code 33968.

Correspondence Language Policy/Example Number 15.30000 – Medically Unlikely Edits (Units of Service) For example, CPT code 33470 (Valvotomy, pulmonary valve, closed heart; transventricular) may be reported with a maximum of one unit of service on a single date of service since the heart has one pulmonary valve. If units of service in excess of one are reported, the MUE prevents payment.

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Digestive System CPT Codes 40000-49999

Correspondence Language Policy/Example Number 2.40000 - HCPCS/CPT procedure code definition For example, the code descriptor for CPT code 45805 is “Closure of rectovesical fistula; with colostomy” and the code descriptor for CPT code 45800 is “Closure of rectovesical fistula;”. Therefore, based upon the code descriptors the procedure described by CPT code 45800 is a component of the procedure described by CPT code 45805, and CPT code 45800 is bundled into CPT code 45805.

Correspondence Language Policy/Example Number 3.40000 - CPT Manual and CMS coding manual instructions For example, the CPT Manual instruction above CPT code 49491 states: “With the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other prostheses is not separately reported.” Therefore, CPT code 49568 (mesh implantation) should not be reported separately with CPT code 49505 (inguinal hernia repair).

Correspondence Language Policy/Example Number 4.40000 - Mutually exclusive procedures For example, CPT codes 43100 and 43101 describe different approaches to the excision of an esophageal lesion. CPT code 43100 describes a cervical approach, and CPT code 43101 describes a thoracic or abdominal approach. Since both procedures would not be performed at the same patient encounter, the two procedures are mutually exclusive of one another.

Correspondence Language Policy/Example Number 5.40000 - Sequential procedures For example, if an anoscopy with control of bleeding (CPT code 46614) is unsuccessful and is followed by a complex or an extensive internal and external hemorrhoidectomy (CPT code 46260), only CPT code 46260 may be reported. Therefore, CPT code 46614 is not separately reportable with CPT code 46260.

Correspondence Language Policy/Example Number 6.40000 – CPT “separate procedure” definition For example, the code descriptor for CPT code 44005 (“Enterolysis (freeing of intestinal adhesion) (separate procedure)”) includes the “separate procedure” designation. When a partial colectomy with anastomosis (CPT code 44140) is performed, the procedure described by CPT code 44005 is not a separate procedure. Therefore, CPT code 44005 cannot be reported separately and is bundled into CPT code 44140.

Correspondence Language Policy/Example Number 7.40000 - More extensive procedure For example, CPT code 42426 describes excision of a parotid gland tumor with radical neck dissection. CPT code 42425 describes excision of a parotid gland tumor without a radical neck dissection. The procedure described by CPT code 42426 is more extensive than the procedure described by CPT code 42425. Therefore, CPT code 42425 is bundled into CPT code 42426.

Correspondence Language Policy/Example Number 10.40000 - Standards of medical/surgical practice For example, during a tonsillectomy (CPT code 42821) bleeding may occur. The control of such bleeding intraoperatively is a standard of surgical practice. It is inappropriate to report separately CPT code 42961 (control of oropharyngeal hemorrhage). Therefore, CPT code 42961 is bundled into CPT code 42821.

Correspondence Language Policy/Example Number 11.40000 - Anesthesia included in surgical procedures For example, if an ilioinguinal or iliohypogastric nerve block (CPT code 64425) is performed for anesthesia by the physician performing an inguinal hernia repair (CPT code 49505), the nerve block is included in the surgical procedure and is not reported separately. Therefore, CPT code 64425 is bundled into CPT code 49505.

Correspondence Language Policy/Example Number 14.40000 - Misuse of column two code with column one code

For example, CPT code 91105 (“Gastric intubation, and aspiration or lavage for treatment (eg, for ingested poisons)”) describes a non-endoscopic procedure. It is a misuse of this code to report it for lavage performed during an upper gastrointestinal endoscopy procedure such as CPT code 43227 (“Esophagoscopy, rigid or flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)”). Therefore, CPT code 91105 is bundled into CPT code 43227. CPT code 91105 should not be reported separately unless it is performed as a distinct, non-endoscopic procedure.

Correspondence Language Policy/Example Number 15.40000 – Medically Unlikely Edits (Units of Service) For example, CPT code 44950 (Appendectomy) may be reported with a maximum of one unit of service since there is only one appendix. If units of service in excess of one are reported, the MUE prevents payment.

National Correct Coding Initiative’s Correspondence Language

Section-specific Examples

Urinary System, Male Genital System, Intersex Surgery, Female Genital System, Maternity Care and Delivery CPT Codes 50000-59999

Correspondence Language Policy/Example Number 2.50000 - HCPCS/CPT procedure code definition For example, the code descriptor for CPT code 51925 is “Closure of vesicouterine fistula; with hysterectomy”, and the code descriptor for CPT code 51920 is “Closure of vesicouterine fistula;”. Therefore, based upon the code descriptors the procedure described by CPT code 51920 is a component of the procedure described by CPT code 51925, and CPT code 51920 is bundled into CPT code 51925.

Correspondence Language Policy/Example Number 3.50000 - CPT Manual and CMS coding manual instructions For example, the parenthetical note following CPT code 58146 states: “(Do not report 58146 in addition to 58140-58145, 58150-58240)”. Therefore, CPT code 58146 is not separately reportable with CPT code 58150.

Correspondence Language Policy/Example Number 4.50000 - Mutually exclusive procedures For example, CPT codes 50800 and 50860 describe different types of ureteral diversion procedures. CPT code 50800 describes diversion to the intestine, and CPT code 50860 describes diversion to the skin (ureterostomy). Since both procedures would not be performed on the same ureter at the same patient encounter, the two procedures are mutually exclusive of one another.

Correspondence Language Policy/Example Number 5.50000 - Sequential procedures For example, if a needle or punch biopsy of the prostate by any approach (CPT code 55700) is unsuccessful and is followed at the same patient encounter by an incisional biopsy of the prostate (CPT code 55705), only CPT code 55705 may be reported. Therefore, CPT code 55700 is bundled into CPT code 55705.

Correspondence Language Policy/Example Number 6.50000 – CPT “separate procedure” definition For example, the code descriptor for CPT code 49000 (“Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure)”) includes the “separate procedure” designation. When a total abdominal hysterectomy, with or without removal of tubes and/or ovaries (CPT code 58150) is performed, the procedure described by CPT code 49000 is not a separate procedure. Therefore, CPT code 49000 cannot be reported separately and is bundled into CPT code 58150.

Correspondence Language Policy/Example Number 7.50000 - More extensive procedure For example, CPT code 54530 describes a radical orchiectomy through an inguinal approach. Since a partial orchiectomy (CPT code 54522) removes a smaller portion of the testis, the procedure described by CPT code 54530 is more extensive than the one described by CPT code 54522. Therefore, CPT code 54522 is bundled into CPT code 54530.

Correspondence Language Policy/Example Number 9.50000 - Gender-specific (formerly Designation of sex) procedures For example, CPT code 52270 describes a cystourethroscopy with an internal urethrotomy for a female, and CPT code 52275 describes the identical procedure for a male. The two procedures cannot be reported for the same beneficiary. Therefore only the appropriate code should be reported.

Correspondence Language Policy/Example Number 10.50000 - Standards of medical/surgical practice For example, CPT code 51820 describes a cystourethroplasty with unilateral or bilateral ureteroneocystostomy. CPT code 51701 describes an insertion of a non-dwelling bladder catheter and may be performed as a standard of medical/surgical practice prior to performing a cystourethroplasty with ureteroneocystostomy (CPT code 51820). Therefore, CPT code 51701 is bundled into CPT code 51820.

Correspondence Language Policy/Example Number 11.50000 - Anesthesia included in surgical procedures

For example, when an incision and drainage of a Bartholin’s gland abscess (CPT code 56420) is performed and anesthesia is also performed by the surgeon (CPT code 00940), separate reporting for the anesthesia service is inappropriate. Therefore, CPT code 00940 (anesthesia for vaginal procedures) is bundled into CPT code 56420.

Correspondence Language Policy/Example Number 14.50000 - Misuse of column two code with column one code For example, an incidental appendectomy during another intra-abdominal surgical procedure should not be reported separately. It is a misuse of CPT code 44950 (“Appendectomy”) to report it for an incidental appendectomy during the procedure described by CPT code 58150 (Total abdominal hysterectomy, with or without removal of tube(s), with or without removal of ovary(s)). Therefore, CPT code 44950 is bundled into CPT code 58150.

Correspondence Language Policy/Example Number 15.50000 – Medically Unlikely Edits (Units of Service) For example, CPT code 55840 (Prostatectomy, retropubic radical, with or without nerve sparing) may be reported with a maximum of one unit of service because there is only one prostate gland in males. If units of service in excess of one are reported, the MUE prevents payment.

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Endocrine System, Nervous System, Eye and Ocular Adnexa, Auditory System, Operating Microscope CPT Codes 60000-69999

Correspondence Language Policy/Example Number 2.60000 - HCPCS/CPT procedure code definition For example, the code descriptor for CPT code 67039 is “Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation” and the code descriptor for CPT code 67036 is “Vitrectomy, mechanical, pars plana approach;”. Therefore, based upon the code descriptors the procedure described by CPT code 67036 is a component of the procedure described by CPT code 67039, and CPT code 67036 is bundled into CPT code 67039.

Correspondence Language Policy/Example Number 3.60000 - CPT Manual and CMS coding manual instructions

For example, CPT code 66711 describes a ciliary body destruction with endoscopic cyclophotocoagulation. The CPT Manual instruction following CPT code 66711 states: “(Do not report 66711 in conjunction with 66990)”. Therefore, CPT code 66990 for use of ophthalmic endoscope is bundled into CPT code 66711.

Correspondence Language Policy/Example Number 4.60000 - Mutually exclusive procedures For example, CPT codes 69433 and 69436 describe different types of tympanostomy requiring insertion of ventilating tube. CPT code 69433 describes the procedure performed with local or topical anesthesia, and CPT code 69436 describes the procedure performed with general anesthesia. Since both procedures would not be performed at the same patient encounter, the two procedures are mutually exclusive of one another.

Correspondence Language Policy/Example Number 5.60000 - Sequential procedures For example, if a fine needle aspiration of the thyroid (CPT code 10021) is unsuccessful and is followed at the same patient encounter by a percutaneous core needle biopsy of the thyroid (CPT code 60100), only CPT code 60100 may be reported. Therefore, CPT code 10021 is not separately reportable with CPT code 60100.

Correspondence Language Policy/Example Number 6.60000 – CPT “separate procedure” definition For example, the code descriptor for CPT code 65860 (“Severing adhesions of anterior segment, laser technique (separate procedure)”) includes the “separate procedure” designation. When a trabeculoplasty by laser surgery (CPT code 65855) is performed, the procedure described by CPT code 65860 is not a separate procedure. Therefore, CPT code 65860 cannot be reported separately and is bundled into CPT code 65855.

Correspondence Language Policy/Example Number 7.60000 - More extensive procedure For example, CPT code 67228 describes destruction of extensive diabetic retinopathy by photocoagulation. CPT code 67208 describes destruction of a localized retinal lesion by cryotherapy. The procedure described by CPT code 67228 is more extensive than the procedure described by CPT code 67208. Therefore, CPT code 67208 is bundled into CPT code 67228.

Correspondence Language Policy/Example Number 10.60000 - Standards of medical/surgical practice

For example, CPT code 60240 describes a total or complete thyroidectomy. CPT code 60500 describes a parathyroidectomy or exploration of parathyroid(s).

The exploration of parathyroid glands with or without parathyroidectomy (CPT code 60500) is standard surgical practice when performing a complete thyroidectomy (CPT code 60240). Therefore, CPT code 60500 is bundled into CPT code 60240.

Correspondence Language Policy/Example Number 11.60000 - Anesthesia included in surgical procedures For example, if the surgeon performing a cataract extraction (CPT code 66984) also provides anesthesia (CPT code 00142), the anesthesia service is not reported separately. Therefore, CPT code 00142 is bundled into CPT code 66984.

Correspondence Language Policy/Example Number 14.60000 - Misuse of column two code with column one code

For example, CPT code 20550 (“Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)”) describes a therapeutic musculoskeletal injection. It is a misuse of this code to report it for the injection of local anesthesia in order to perform another procedure such as a carpal tunnel release (CPT code 64721). Therefore, CPT code 20550 is bundled into CPT code 64721.

Correspondence Language Policy/Example Number 15.60000 – Medically Unlikely Edits (Units of Service) For example, since CPT code 69210 (Removal impacted cerumen (separate procedure), one or both ears) includes removal of cerumen from one or both ears, this code may be reported…