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Published Date:12/01/2020

Printed Date: 9/22/2015

URL: http://palmgba.com/marlowe/redesign6/article.html

We are receiving a bundling denial even though we submitted a CPT modifier to indicate the service was distinct or independent from the other non-E/M services performed on the same day. Why is the service being denied?

Answer
There are two reasons your service may be denied, even though you submitted it with CPT modifier 59.

The most common reason is that you submitted CPT modifier 59 with the "Column I" code instead of the "Column II" code.

Codes are bundled in pairs. The primary code is a Column I code, and the component code is a Column II code. The CCI edit list shows which codes are in which columns.
If documentation in the patient’s medical record supports the use of CPT modifier 59 for your code pair (containing a Column I and Column II code), the CPT modifier must be submitted with the Column II code only
If you submit CPT modifier 59 with the Column I code instead, the service may still be denied
Check the columns before submitting CPT modifier 59 to ensure that you are submitting it with the component (Column II) procedure

You may also have received a denial because the code pair cannot be unbundled.

Code pairs identified with indicator "0" in the CCI list cannot be submitted separately for reimbursement under any circumstances. There are no exceptions to the CCI edits for indicator "0" codes.
Code pairs identified with indicator 1 may be submitted separately for reimbursement if the two services are performed in a different session or patient encounter; different procedure or surgery; different site or organ system; separate incision/excision; or separate lesion or injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. Documentation must be maintained in the medical record to support the use of this modifier. No special documentation is required with the claim when CPT modifier 59 is submitted.
Code pairs identified with indicator 9 are not subject to CCI edits. No modifier is required in these situations.
Check the indicator for the CCI code pair before submitting CPT modifier 59

Resource: CMS National Correct Coding Initiative web page.

Last Updated: 12/01/2020

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