CMS releases 2024 first and second quarter NCCI edits
Derm Coding Consult
By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Manager, Lead Coding and Reimbursement Strategist, August 1, 2024
Academy coding staff address important coding topics each month in DermWorld Coding Consult. Read more Coding Consult articles.
CMS released the first and second quarter National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edit files. Versions 30.0 and 30.1 went into effect on Jan. 1, and April 1, 2024, respectively.
There are no medical or surgical dermatology-specific changes in these edit files.
CMS NCCI edits: Overview
CMS establishes coding policies based on the guidelines provided by the American Medical Association (AMA), Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT), national and local coverage determinations (NCD/LCD), national societies’ coding guidelines, and the standard medical and surgical practices. This approach ensures that the coding policies align with widely recognized and accepted standards in the health care industry.
The NCCI PTP code pair edits are designed to prevent incorrect payment when mutually exclusive procedures are reported together. CMS houses the code pair edits in an Excel table formatted with Column One and Column Two. When both codes in a pair are reported on the same service date, one of the codes is deemed eligible for reimbursement, while the other is not, unless a clinically appropriate NCCI PTP-associated modifier is appended to one of the two codes in the code pair. Medicare allows for an appropriate NCCI-associated modifier to be appended to either of the codes in the code pair, unlike some private payers who prefer the NCCI-associated modifier to be appended to the code in column two.
Note: Check directly with private payers for the correct modifier placement policy as they may vary from Medicare policies.
The table uses a Correct Coding Modifier Indicator (CCMI) to indicate the status of the reported code combination, providing important information for accurate billing and reimbursement processes.
Medicare NCCI Procedure to Procedure (PTP) Edits
See the CMS resource Medicare NCCI Procedure to Procedure (PTP) Edits.
Correct Coding Modifier Indicators
The indicator determines if an NCCI-associated modifier (see list below) will allow the code pair to bypass edits and reimburse both services/procedures.
The modifier indicator “0” signifies that no NCCI-associated modifier will bypass the edit(s). Indicator “1” means that an NCCI-associated modifier will bypass the edit(s), and indicator “9” means that the code combination edit has been deleted and no NCCI-associated modifier is required. The following table includes only a few examples of PTP code pairs.
| CCMI | CCMI descriptor | Code combination example, Column 1 | Code combination example, Column 2 | Rationale | Resolve |
|---|---|---|---|---|---|
0 |
An NCCI-associated modifier is not allowed and will not bypass the edit. |
11106 |
11104 |
CPT Manual |
Codes with this CMMI cannot be paid for the same patient on the same DOS by the same provider. Only one primary skin biopsy code can be reported on the same DOS. The incisional biopsy is reported as primary code; report an add-on code for the punch biopsy |
1 |
An NCCI-associated modifier is allowed and will bypass the edit. |
11102 |
17260 |
Mutually |
Edit can be bypassed, and the column two code may be eligible for payment if an NCCI-associated modifier is appropriately appended to one of the codes. |
9 |
The use of NCCI-associated modifiers is not specified. This indicator is used for all code pairs that have a deletion date that is the same as the effective date. |
11201 |
11300 |
Mutually |
This indicator was Edit expired 6/1/1996 |
NCCI-associated modifiers that are allowed to bypass an NCCI PTP code pair edit:
Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
Global surgery modifiers: 24, 25, 57, 58, 78, 79
Other modifiers: 59, 91, XE, XS, XP, XU
Medicare NCCI Policy Manual
The NCCI Policy Manual is a crucial resource for accurately billing Medicare-approved services. Developed and regularly updated by CMS, this manual provides detailed explanations of various Medicare billing requirements and restrictions. It includes information about the medical and surgical package, evaluation and management (E/M) services, and Medically Unlikely Edits (MUEs). Dermatologists and non-physician clinicians (NPCs) would benefit from the information found in Chapter 1 - General Correct Coding Policies, and Chapter 3 - Surgery: Integumentary System CPT Codes 10000 – 19999.
Most private payers integrate these guidelines into their claim adjudication policies. In cases of coding or billing conflicts between CMS and CPT coding guidelines when reporting services for Medicare beneficiaries, CMS rules supersede all others.
Medicare NCCI Medically Unlikely Edits (MUEs)
Learn more from CMS about Medicare NCCI Medically Unlikely Edits (MUEs).
Frequently asked questions
Q. When performed on the same day, which code should be reported with modifier 59, 17110 or 17000?
A. According to the NCCI Edits, modifier 59 is required on one of the codes in this CPT code combination. Some private payers would prefer the NCCI-associated modifier 59 to be placed on CPT code 17000.
Q. What modifier would be appropriate for CPT code combinations 11102, 17273, and 13132 when reported on the same date of service for the same patient encounter?
A. According to the Medicare NCCI edits, modifier 59 is required on both CPT codes 13132 and 11102 as follows:
17273
13132 - 59
11102 - 59
Q. A claim for intralesional injection with codes 11900 – 59 and J3301 – 59 was submitted to a private payer and denied. For correct claim adjudication, how should this encounter be reported?
A. According to the NCCI edits, a modifier is not required to be appended for this claim combination. The claim is denied due to modifier misuse. In this circumstance, it is appropriate to submit a corrected claim as follows:
11900 x 1 unit
J3301 x 1 unit (include NDC # listed on the medication package or bottle)
Q. Why did a claim submitted with benign excision CPT code 11400 and intermediate repair code 12032 get denied?
A. According to the NCCI Edits Coding Policy Manual Chapter 3 - Surgery: Integumentary System Section E. 6 (pp III-7) states that an excision of benign lesions with excised diameter of 0.5 cm or less (CPT codes 11400, 11420, 11440) includes simple, intermediate, or complex repairs which shall not be reported separately. As such, the intermediate repair code 12032 cannot be reported as this would constitute unbundling.
However, if CPT code 11400 is reported with 12032 for closure on a different defect it will require the use of modifier 59 to indicate that the repair was performed on a different defect from the benign excision.
Visit the Academy’s Coding Resource Center at staging.aad.org/coding for additional guidance and more coding resources.
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