You Asked, We Delivered: Academy Achieves Modification to NCCI Edit for CPT 69424
In early 2013, the Academy was approached by several members and coding experts regarding frequent denials by Medicare Administrative Contractors (MACs) for claims which listed CPT 69424 Ventilating tube removal requiring general anesthesia with a modifier. In response, the Academy researched the issue and found that the current National Correct Coding Institute (NCCI) Edit in place for 69424 was an edit of “0” which means that there are no circumstances for which a modifier would be appropriate to be reported in conjunction with 69424. In fact, the parenthetical in the CPT book under 69424 states: (Do not report code 69424 in conjunction with 69205, 69210, 69420, 69421, 69433-69676, 69710-69745, 69801-69930).
Upon review of this information, the Academy agreed with members that the parenthetical, and associated NCCI edit of “0”, were inappropriate given that these code combinations could be provided contralaterally (i.e. separate services performed on opposite ears) in some clinical scenarios and in those instances, these services should be separately reported and reimbursed. As such, the Academy crafted a letter to NCCIs Medical Director which was delivered on February 11, 2013, requesting
that the CCI edit for CPT 69424 be modified from a “0” to a “1”, which would allow the use of modifiers when 69424 is performed on one side and an exclusionary code in the CPT parenthetical (listed above) is performed on the other side.
The NCCI Medical Director responded to our request expeditiously, and on February 21, 2013 the Academy was informed that our requested modification from a CCI edit of “0” to “1” was approved and would become effective July 1, 2013. This modification will allow surgeons to correctly code for uncommon, but medically appropriate, clinical scenarios where 69424 and one of the following codes (69205, 69210, 69420, 69421, 69433-69676, 69710-69745, 69801-69930) are performed on opposite ears.
The Academy is very pleased that CMS, and the NCCI, have agreed to implement this change. To access the full response from NCCI, visit:
http://bit.ly/NCCIMUE. We encourage members to keep health policy staff abreast of any similar coding issues they encounter in the future, and urge you to contact us with any questions related to this issue or other coding and reimbursement matters.
Approved July 2013
Important Disclaimer Notice (Updated 8/7/14)
CPT for ENT articles are a collaborative effort between the Academy’s team of CPT Advisors, members of the Physician Payment Policy (3P) workgroup, and health policy staff. Articles are developed to address common coding questions received by the health policy team, as well as to clarify coding changes and correct coding principles for frequently reported ENT procedures. These articles are not intended as legal, medical, or business advice and are not a guarantee of reimbursement. The information is also not meant to serve as the definitive or sole authority on billing and coding issues. The applicability of AAO-HNS billing and coding guidance for a particular procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. You should consult with your own advisors as well as Medicare or private carriers in making any decisions about how to bill and code particular services or procedures.