CCI and Sx Coding

Let's review CMS Policy, so this may not be applicable to all insurance. Column 1 vs Column 2 coding, under the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, the column one code represents the primary procedure, while the column two code is considered a component of the primary procedure. If two codes are bundled in an NCCI edit, it generally means that the column two code is not separately reimbursable when billed with the column one code, unless a modifier (such as Modifier 59 or an appropriate X{EPSU} modifier) is allowed and correctly applied to indicate a separate and distinct service.

However, if only the column two code is performed and documented appropriately without the column one code, then it may be billed on its own. But you cannot selectively bill only the column two code when both procedures were actually performed together, as this would be considered improper coding and could result in claim denials or compliance issues.

you can find official guidance on NCCI Procedure-to-Procedure (PTP) edits directly from CMS (Centers for Medicare & Medicaid Services). Here are some key resources:

1. NCCI Policy Manual for Medicare – This manual provides detailed explanations of bundling rules, including how column one and column two codes function. Policy Manual is here: https://www.cms.gov/files/zip/medicare-ncci-policy-manual-2024.zip

MLN article on NCCI: https://www.cms.gov/Outreach-and-Education/MLN/Educational-Tools/MLN901346-How-to-use-the-Medicare-NCCI/ncci-medicare/chapter_2_using_the_ncci_tools/#:~:text=When%20is%20a%20Code%20the,X%7BEPSU%7D%20fact%20sheet.

2. NCCI PTP Coding Edits – This tool allows you to check specific CPT code pairs to determine if they are bundled and whether a modifier can be used.

• Access it here: CMS NCCI Edits-https://www.cms.gov/medicare/coding-billing/ncci-medicare

3. Medicare Claims Processing Manual, Chapter 23 (Section 20.9) – This provides official instructions for applying NCCI edits in billing.

• Medicare Claims Processing Manual-https://www.cms.gov/medicare/regulations-guidance/manuals/internet-only-manuals-ioms

I guess then the question for everyone would be "What are my obligations for reporting Column 1 code if they only wish to bill and document the Column 2 code?

I am not sure you answered the posters question. Yes the column 2 is code is included in a Column 1 code, but the Column 2 code is a stand alone code, which means it can be billed independently. Thus the ? can the provider simply "eat" the Column 1 code and not bill it, even though they documented that they performed it.

In plain language, does anyone have a citation which specifically mandates that all procedures performed be billed?

To clarify, I assume you are asking this question about two services performed on the same DOS and on the same anatomical site. That is both the Column I (a lower fee) code is billed at the same time that the Column II (a higher fee) code is performed. If that is correct, then...

Medicare stipulates that you must document all procedures that were performed. I think what you are asking here is whether you choose to bill for all those services that you performed may be thought of as a separate and distinct issue.

In my opinion, Medicare doctrine stipulates that you must document what you performed and that in order to bill for something you must have it documented.

Those statements don't require you however to bill for everything you performed, in particular for services which are non covered.

Then there is also the looming issue here of purposely not billing everything which was performed in order to avoid being paid the lower fee for the Column I code by not billiing for it.

If you don't document that you performed a particular service, then there could be a looming professional liabilty issue on whether or not you followed SOC.

I don't have a definitive opinion on this and I am interested in hearing what others might have to say to continue this debate...