Established Patient Office Visits: NCCI Bundling Denials

Denial Reason, Reason/Remark Code(s)
•    M-80: Not covered when performed during the same session/date as a previously processed service for the patient
•    CO-B15: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
•    CPT code: 99211

National Correct Coding Initiative
The National Correct Coding Initiative (NCCI) packages or 'bundles' reimbursement for some services under Medicare. NCCI identifies code pairs that are never reimbursed separately and code pairs that can only be reimbursed separately in certain circumstances (identified by the appropriate modifier).

Resources
•    Check NCCI edits prior to claim submission; edits are updated quarterly.
•    Use the Palmetto GBA NCCI tool to determine if the service you are submitting is bundled with another service
•    CPT code 99211 is bundled with many CPT codes
o    If CPT code 99211 is marked with indicator '0' in the NCCI edit list, it cannot be reimbursed separately from other procedures. Do not submit the service.
o    If CPT code 99211 is a separate, distinct service and is marked with indicator '1' in the NCCI edit list, submit CPT modifier 25 to denote it as a separate service
•    Examples of separate, distinct services include situations in which the minimal office visit was performed a different patient encounter from the procedure with which it is bundled. Supporting documentation is required in the medical records.
•    For additional, specific information on modifiers that may be used to denote exceptions to NCCI (including CPT modifier 25

E/M Services: CCI Bundling Denials
Denial Reason, Reason/Remark Code(s)
•    M80: Not covered when performed during the same session/date as a previously processed service for the patient
•    CO-B15: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
Correct Coding Initiative: The Correct Coding Initiative (CCI) packages (bundles) reimbursement for some services under Medicare. CCI identifies code pairs that are never reimbursed separately and code pairs that can only be reimbursed separately in certain circumstances (identified by the appropriate modifier).

Resolution/Resources

•    Check CCI edits prior to claim submission; edits are updated quarterly. CCI edits are available on the CMS website.
•    For specific information on modifiers that may be used to denote exceptions to CCI (including CPT modifiers 24, 25, 59, 76 and 91), refer to the Palmetto GBA Modifier Lookup tool located on our home page under Self Service Tools 

Is the E/M a significant, separately identifiable service?
If the answer is no, the service will not be reimbursed separately. If the answer is yes, submit CPT modifier 25;

Is the CCI indicator '0'?
These code pairs will not be reimbursed if submitted for the same date of service. Exceptions to CCI edits cannot be made for code combinations with an indicator of '0'.

Is the code indicator '1'?
Submit the appropriate modifier to show the service should be separate. Documentation is required in the patient's medical record. Exceptions to CCI edits can be made for code combinations with an indicator of '1'. Examples of separate, distinct services include situations in which the E/M visit was performed at a different patient encounter from the procedure with which it is bundled.