National Correct Coding Initiative Edits (NCCI) - JE Part B
National Correct Coding Initiative (NCCI)
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 circumstances 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.
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}