National Correct Coding Initiative Edits (NCCI) - JE Part B - Noridian (2024)

The purpose of the NCCI Procedure-to-Procedure (PTP) edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table have been combined into one table and include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual. See the CMS NCCI Coding Edits to determine if the service being submitted is bundled with another service.

Column One/Column Two Correct Coding Edits Table

Column 1: Comprehensive or major code

Column 2: Secondary or component code

In Existence Prior to 1996: * indicates edit was in effect prior to 1996

Effective Date: Indicates effective date of the edit

Deletion Date: Indicates deletion date of the edit, if applicable

Modifier: Indicates if use of a modifier is permitted

• 0: Codes should never be reported together by the same provider for the same beneficiary on the same date of service; if reported on the same date of service, the column one code is eligible for payment and the column two code is denied
• 1: Codes may be reported together only in defined circ*mstances by use of NCCI-associated modifier
• 9: Not applicable

Exceptions to NCCI bundling must be documented in the patient's medical records and submitted with the appropriate modifier(s). These ‘exception' modifiers must be submitted with the correct CPT or HCPCS code. Examples of modifiers used to indicate a separate procedure, different organ or anatomic clarity are (not all-inclusive list):

• Modifier 59: Distinct or independent service performed on the same day (or XE, XS, XP, XU)
• RT and LT: Right and left side of body
• E1-E4: Eyelid
• FA, F1-F9: Hand modifiers
• TA, T1-T9: Feet modifiers

Modifier 59 or XE, XP, XS, XU should not be appended to:

• Evaluation and Management (E/M) service – to report a separate and distinct E/M service with a non-E/M service performed on the same date, modifier 25 is used
  • Includes ophthalmology codes 92012-92014
• Weekly radiation code 77427 Radiation treatment management, 5 treatments

When a provider or supplier submits a claim for any of the codes specified above with the 59 or XE, XP, XS, XU modifier, the claim will be processed as if the modifier were not present.

PTP Edit Rationale: Indicates the reason for the correct coding edit. CMS provides rationale for the edit in the NCCI General Correspondence Language and Section-specific Examples (for NCCI Procedure to Procedure (PTP) Edits and MUEs.

• Standard Preparation/Monitoring Services for Anesthesia
  • Anesthesia services require certain services to prepare patient prior to administration of anesthesia and to monitor patient during course of anesthesia
• HCPCS/CPT Procedure Code definition
  • All services described by HCPCS/CPT code must be performed
• CPT Manual or CMS Manual Coding Instruction
  • CMS issues coding instructions and guidelines in its manuals, program memoranda and other publications
• Mutually Exclusive Procedures
  • Certain services or procedures would not reasonably be performed at the same session by the same provider on the same beneficiary
• Sequential Procedure
  • Less extensive procedure fails and requires performance of a more extensive procedure
• CPT "Separate Procedure" Definition
  • "Separate procedure" should not be reported when performed along with another procedure in anatomically-related region through same skin incision or surgical approach
• More Extensive Procedure
  • HCPCS/CPT codes corresponding to more extensive procedures always include HCPCS/CPT corresponding to less complex procedures
• Gender-Specific Procedures
  • Some HCCPS/CPT code descriptors are designated to be reported for male or female
• Standards of Medical/Surgical Practice
  • Many procedures typically necessary to complete more comprehensive procedure are assigned independent HCPCS/CPT codes because they may be performed independently in other settings
• Anesthesia Service Included in Surgical Procedure
  • HCPCS/CPT codes describing anesthesia services or services bundled into anesthesia services should not be reported in addition to surgical procedure requiring the anesthesia service
• Laboratory Panel
  • HCPCS/CPT codes identifying individual tests included in laboratory panels should not be reported separately
• Deleted/Modified Edits for NCCI
  • Based on input from many sources, some edits are deleted
• Misuse of Column Two Code with Column One Code
  • Physician or non-physician provider must perform all services noted in the descriptor unless descriptor states otherwise
• Medically Unlikely Edits
  • Values set based on anatomic considerations, HCPCS/CPT code descriptors, coding instructions, CMS policies, nature of service and clinical judgement

These tables are updated by CMS on a quarterly basis.

Use of an Advance Beneficiary Notice of Noncoverage (ABN) is not appropriate for NCCI situations.

Questions/Concerns

You may submit inquiries about the NCCI program, including those related to NCCI (PTP, MUE, and Add-on Code) edits, in writing via email to NCCIPTPMUE@cms.hhs.gov.

Any submissions made to the NCCI program that contain Personally Identifiable Information (PII) or Protected Health Information (PHI) are automatically discarded, regardless of the content.

Inquiries about a specific claim or how to submit an appeal should be addressed to the Medicare Administrative Contractor (MAC).

Resources

• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9
• CMS NCCI Correspondence Language Manual
• CMS NCCI Policy Manual
• CMS Medicare National Correct Coding Initiative (NCCI) Edits
• How to Use the Medicare NCCI Tools
• Proper Use of Modifiers 59 & -X{EPSU}