CMS releases 2024 third and fourth quarter NCCI edits
Derm Coding Consult
By Tiffany E. McFarland, RHIT, Analyst, Coding & Reimbursement, February 1, 2025
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CMS has released the third and fourth quarter updates to the 2024 National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits for 2024. These updates are now available on the Medicare-Medicaid Coordination Office website in the Fraud, Waste, and Abuse (FWA) Prevention section. NCCI edits versions 30.2 and 30.3 went into effect on July 1, 2024, and Oct. 1, 2024, respectively. Access the latest NCCI PTP Edits on the CMS website.
NCCI PTP code pairs edits overview
The NCCI PTP code pair edits aim to prevent improper payments by ensuring that procedures, which are typically not billed together, are not reported on the same date unless clinically appropriate. CMS offers a downloadable Excel file that lists PTP code pair edits, with each pair displayed in two columns. Column One and Column Two include CPT/HCPCS codes, along with a Correct Coding Modifier Indicator (CCMI) to specify the conditions under which a claim edit can be bypassed. If both codes in a pair are submitted on the same service date, only the Column One code is eligible for reimbursement unless the edit is overridden by a valid modifier that justifies separate reporting.
Correct Coding Modifier Indicators
The CCMI is critical for deciding when a modifier can allow reimbursement for both codes in a pair:
CCMI “0”: This code pair cannot be bypassed with a modifier; only the Column One code will be reimbursed.
CCMI “1”: A valid modifier can bypass the edit, allowing both codes to be reported and reimbursed.
Modifier 59 is one of the most crucial yet frequently misused modifiers, often resulting in audits. It is used to override NCCI edits when reporting separate services or procedures, but only when specific criteria are met. With the 2024 updates emphasizing the importance of accurate billing, CMS highlights the importance of clear and detailed documentation when using modifier 59 or similar modifiers to bypass edits. Dermatologists and non-physician clinicians (NPCs) should include thorough documentation, including the location of each lesion or procedure site and the rationale for applying each modifier. This comprehensive documentation is essential for submitting accurate claims and complying with CMS requirements.
Other 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: 91, XE, XS, XP, XU
Medically Unlikely Edits
Like NCCI edits, Medically Unlikely Edits (MUEs) are updated quarterly to help prevent excessive or incorrect billing. An MUE defines the maximum number of units of a HCPCS/CPT code that a dermatologist or NPC may report for a single beneficiary on a single date of service. See these MUEs at the CMS website.
MUE units for HCPCS/CPT codes are determined by an MUE Adjudication Indicator (MAI), which outlines the type and rationale behind each MUE. An MAI of “1” means the MUE is applied per claim line, and modifiers 59, 76, 77, and 91 can be used to report more units of service. An MAI of “2” applies to “per day” edits based on policy, limiting the units allowed on the same date of service due to anatomical or coding constraints. These edits are based on statute, regulation, and CMS guidelines.
Below is an illustration of the MAI indicators:
| MUE Adjudication Indicator | MUE rationale | Action | Example |
|---|---|---|---|
1 - Claim line edit |
Clinical: |
Maximum MUE units must be adhered to on the date of service (DOS) |
HCPCS code A6460 - Synthetic resorbable wound dressing, sterile, pad size 16 sq in or less, without adhesive border, each dressing |
2 - Date of service edit: Policy |
Code descriptor/ |
Absolute date of service edit |
CPT code 11102 – Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); single lesion. |
3 - Date of service edit: Clinical |
Clinical: Data |
“Per day” edit based on clinical benchmarks |
CPT code 11400 - Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less |
New MUE limit for dermatology
HCPCS code J7354 – Cantharidin for topical administration, 0.7%, single unit dose applicator (3.2 mg) has a new MUE limit of 2 units per day.
These updates aim to streamline billing practices and help dermatologists avoid unintentional bundling errors. Visit the Academy’s Coding Resource Center at staging.aad.org/coding for additional guidance and more coding resources.
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