February 2016

Action:

Due to a Center for Medicare/Medicaid Services National Correct Coding Initiative systems processing error with EBUS codes, ATS is advising members to hold submission of claims for EBUS code services (CPT 31652, 31653, 31654) until after April 1, 2016.

For EBUS claims that were submitted between Jan. 1, 2016 and March 31, 2016, the ATS recommends members plan to re-adjudicate these claims after April 1, 2016.

Background:

On Jan. 1, 2016, AMA CPT retired CPT code 31620, and implemented three new codes to report EBUS services:

• 31652 with EBUS guided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures.
• 31653 with EBUSguided transtracheal and/or transbronchial sampling (e.g., aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures.
• +31654 with transendoscopic EBUS during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s). (List separately in addition to code for primary procedure[s] .)

As typical with any new codes, CMS/NCCI implements new code pair edits on the same date as the codes are active for use with providers. Unfortunately due to an implementation problem, some inappropriate code pair edits are now causing correctly coded claims to be rejected, denied, or improperly adjudicated (i.e., underpaid). As an example, if a bronchoscopy included an EBUS-guided aspiration of two lymph node stations (31652) and any additional sampling procedure (31623-29), the inappropriate CCI edits would deny, reject, or improperly adjudicate the additional codes or the entire claim.

ATS notified the NCCI contractor of this issue and the CMS agreed to delete the edits at the next possible NCCI update, April 1, 2016. For more details on the code pairs that are affected by this issue, click here to see the letter from the NCCI contractor.

Since CMS only updates these edits quarterly, claims will continue to be rejected up until the next file is implemented on April 1, 2016. Therefore, members are advised to either hold claims reporting EBUS services until April 1, 2016, or plan to re-adjudicate any submitted claims (for EBUS services performed between Jan. 1, 2016 through March 30, 2016) on or after April 1, 2016. Providers may also wish to contact their local Medicare contractor for any specific local instructions regarding these code-pair denials. Additionally, since many other payers follow the NCCI edits, we recommend sharing the NCCI letter with those payers for their instructions regarding claims processing.

If you have questions or need additional information regarding EBUS claim submission, please contact the ATS at codingquestions@thoracic.org.