CMS releases 2025 first and second quarter NCCI edits
Derm Coding Consult
By Tiffany E. McFarland, RHIT, Analyst, Coding & Reimbursement, September 1, 2025
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CMS has released the first and second quarter updates to the 2025 National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits. These updates are now available on the Medicare-Medicaid Coordination Office website under the Fraud, Waste, and Abuse (FWA) Prevention section. NCCI edits versions 31.0 and 31.1 went into effect on Jan. 1, 2025, and April 1, 2025, respectively. Access the latest NCCI PTP edits.
There are no dermatology-specific changes in these edit files.
CMS National Correct Coding Initiative edits overview
CMS develops coding policies based on guidelines from the American Medical Association (AMA), Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) coding conventions, national and local coverage determinations (NCD/LCD), national societies’ coding guidelines, and the standard medical and surgical practices.
The NCCI PTP code pair edits aim to prevent improper payment when mutually exclusive procedures are reported together. CMS houses the code pair edits within an Excel Column One and Column Two formatted table. When these code combinations are reported on the same service date, reimbursement will be provided for the Column One code, while the Column Two code will be bundled into the payment for the first-listed code unless a clinically appropriate NCCI PTP-associated modifier is also reported. The table utilizes an indicator known as the Correct Coding Modifier Indicator (CCMI) to indicate the outcome of the reported code combination.
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Correct Coding Modifier Indicators (CCMI)
The indicator determines whether an NCCI-associated modifier (see list below) will allow the code pair to bypass edits and reimburse both codes.
A modifier indicator of “0” means no NCCI-associated modifier will bypass the edit(s), “1” indicates an NCCI-associated modifier will bypass the edit(s), and “9” means that the code combination has been deleted and no NCCI-associated modifier is required.
| 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 or CMS Manual coding instructions |
Codes with this CMMI cannot be paid for the same patient on the same DOS by the same clinician. 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 (e.g., 11105). |
1 |
An NCCI-associated modifier is allowed and will bypass the edit. |
11102 |
17260 |
Mutually exclusive procedures |
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 exclusive procedure |
This indicator was created so that no blank spaces would be in the indicator field. 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
NCCI Policy Manual
The NCCI Policy Manual is an essential resource for ensuring accurate billing of Medicare-approved services. CMS regularly reviews and updates this manual to provide comprehensive guidance on Medicare billing requirements, medical and surgical package, evaluation and management (E/M) services and medically unlikely edits (MUEs).
Understanding this manual helps dermatologists and non-physician clinicians (NPCs) avoid claims denials and payment reductions by providing clear guidance on correctly reporting frequently performed procedures such as biopsies, excision, and other integumentary services. It also clarifies how to appropriately use modifiers, adhere to MUEs, and navigate the global surgical package rules.
Additionally, most private payers adopt CMS’s NCCI guidelines for their claim adjudication processes. A thorough understanding of the NCCI Policy Manual equips dermatologists with the knowledge needed to minimize claim rejections, maximize reimbursement, and ensure accurate billing, significantly reducing administrative burdens, enhancing practice revenue, and supporting ethical compliant billing practices
The NCCI Policy Manual is accessible on the CMS website.
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Frequently asked questions
Q. When a biopsy is performed on the left ear, and three AK destructions on the same date of service, which code requires a modifier?
A. According to the NCCI edits, modifier 59 is not required on either code. However, Medicare and some private payers will require anatomic modifier LT to indicate that the left ear was biopsied.
Q. What modifier would be appropriate for CPT code combinations 11102, 17311, 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:
17311
13132 - 59
11102 - 59
Q. Medicare denied a claim for three malignant excisions for basal cell carcinoma (BCC) — two on the neck and one on the scalp. The denial states, “maximum benefit plan, payer does not support this frequency of services.”
A. The MUE for CPT code 11622 is 2. Additionally, according to CPT coding guidelines for excisions, each code represents a single lesion — do not add the excised diameter of multiple lesions together. Report a separate code for each lesion treated during the encounter. Medicare prefers modifier 76 to be appended to each additional lesion excised, unless otherwise specified.
HCPCS/CPT code | Practitioner services MUE values | MUE Adjudication Indicator | MUE rationale |
|---|---|---|---|
11622 |
2 |
3 Date of Service Edit: Clinical |
Clinical: Data |
In the Billing and Coding article, Repeat or Duplicate Services on the Same Day, Medicare Claims Processing Manual, Pub. 100-04, chapter 34 states that a denial should be expected if identical duplicate services are submitted for the same date of service.
However, if this claim were submitted to a private payer, the additional lesions would be appended with modifier 59.
As such, this encounter would appropriately be reported as follows:
11622
11622 - 76
11622 - 76
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