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

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

Q. What are some examples of CPT bundles?

A. Consider these:

• 66150: Fistulization of sclera for glaucoma; trephination with iridectomy
• 66185: Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft
• 66852: Removal of lens material; pars plana approach, with or without vitrectomy

Also, read the parenthetical instructions associated with a code description; they can guide you when another code is supported. For example:

• 66174: Transluminal dilation of aqueous outflow canal; without retention of device or stent (Do not report 66174 in conjunction with 65820)
• 66185: Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft (Do not report 66185 in conjunction with 67255).

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

A. The phrase “separate procedure” within the CPT description is restrictive in a manner similar to NCCI. The 2021 CPT Professional Edition, Surgery Guidelines instructs:

“Some of the procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term, ‘separate procedure’. The codes designated as ‘separate procedure’ should not be reported in addition to the code for the total procedure or service of which it considered an integral component.” For example:

• 65800: Paracentesis of anterior chamber of eye (separate procedure)
• 65865: Severing adhesions of anterior segment of eye, incisional technique (with or without Injection of air or liquid) (separate procedure); goniosynechiae
• 66682: Suture of iris, ciliary body (separate procedure) with retrieval of suture through small Incision (eg, McCannel suture)

Q. OK, this is helpful; what else?

A. Review the instructions for billing during the global surgery period (Medicare Claims Processing Manual, Chapter 12, §40; https://go.cms.gov/3kgpid2 ). While global surgery periods are set by Medicare and other payers, and are not a CPT instruction, CPT does identify “one or more sessions” or discusses “a defined treatment period.”

See the following instructions: “Codes … include treatment at one or more sessions that may occur at different encounters. … should be reported once during a defined treatment period.”

• 66762: Iridoplasty by photocoagulation (1 or more sessions)
• 67145: Prophylaxis of retinal detachment … without drainage, 1 or more sessions; photocoagulation
• 67210: Destruction of localized lesion of retina, 1 or more sessions; photocoagulation

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

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

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

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

Q. What about using modifier 59?

A. Starting with the premise that unbundling is the exception and not the usual order of the day, CPT instructs, “Modifier -59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury … not ordinarily encountered or performed on the same day by the same individual.”

However, on July 15, 2021, CMS published a clarification regarding the use of the modifier 59 as well as the X-modifiers (https://www.cms.gov/files/document/r10878cp.pdf ). Pertinent points include:

• These modifiers do not require the use of a different diagnosis for each HCPCS/CPT coded procedure Conversely, different diagnoses are not adequate criteria for the use of modifiers 59 or X{EPSU}
• Modifier 59 or X{EPSU} are not appropriate if the basis for their use is that the CPT description of the two codes is different.

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

Suzanne L. Corcoran, COE is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .