CMS releases 2025 third and fourth quarter NCCI edits
Derm Coding Consult
By Tiffany E. McFarland, RHIT, CPCD, CRCR Analyst, Coding & Reimbursement, March 1, 2026
Academy coding staff address important coding topics each month in DermWorld Coding Consult. Read more Derm Coding Consult articles.
CMS has released the third and fourth 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 in the Fraud, Waste, and Abuse (FWA) Prevention section. NCCI edits versions 31.2 and 31.3 went into effect on July 1, 2025, and Oct. 1, 2025, respectively. Access the latest NCCI PTP Edits. There are no dermatology-specific changes in these edit files.
NCCI PTP code pair edits overview
NCCI Procedure-to-Procedure (PTP) edits help prevent incorrect payments by ensuring that certain procedures, which usually should not be billed together, are not reported on the same date unless it is clinically appropriate. CMS provides an Excel file listing these PTP code pairs. Each pair is shown in two columns: Column One and Column Two, which include CPT/HCPCS codes and a Correct Coding Modifier Indicator (CCMI). The CCMI explains when a modifier can override the edit. If both codes in a pair are billed for the same date, only the Column One code will be paid, unless a valid modifier is used to justify separate reporting.
Correct Coding Modifier Indicators (CCMI)
The CCMI tells you if a modifier can allow payment for both codes:
CCMI “0”: The edit cannot be overridden. Only the Column One code will be paid.
CCMI “1”: A valid modifier can override the edit, so both codes can be billed and paid.
CCMI | CCMI descriptor | Code combination example | Rationale | Resolve | |
|---|---|---|---|---|---|
0 |
An NCCI-associated modifier is not allowed and will not bypass the edit. |
Column 1 |
Column 2 |
CPT Manual or CMS 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 (e.g., 11105). |
11106 |
11104 |
||||
1 |
An NCCI-associated modifier is allowed and will bypass the edit. |
11102 |
17260 |
Mutually exclusive procedures |
Edit can be bypassed and the Column 2 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 |
Medicare NCCI Medically Unlikely Edits (MUEs)
Learn more about Medicare NCCI Medically Unlikely Edits (MUEs).
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
Modifier 59 is one of the most misused modifiers, and using it incorrectly can result in rejections, denials, and audits. It is applied to override NCCI edits when reporting separate services or procedures, but only when specific conditions are met. CMS stresses the need for clear and detailed documentation whenever using modifier 59 or similar modifiers to bypass edits. Documentation should include the essential elements of every procedure and must meet medical necessity.
Medicare NCCI Procedure to Procedure (PTP) edits
Learn more about the Medicare NCCI Procedure to Procedure (PTP) edits.
NCCI Policy Manual
The NCCI Policy Manual is a key resource for accurate Medicare-approved services. CMS updates it regularly to provide guidance on billing rules, global surgical packages, evaluation and management (E/M) services, and Medically Unlikely Edits (MUEs).
Understanding this manual helps avoid claim denials and payment reductions by explaining how to correctly report common procedures like biopsies and excisions. It also covers proper modifier use, MUE compliance, and global package rules.
Most private payers follow CMS NCCI guidelines, so having a thorough understanding of the manual helps reduce claim rejections, improve reimbursement, and ensure accurate billing across payers. This proactive approach lowers administrative burden, supports compliance, and boosts revenue.
The CMS NCCI Policy manual is accessible.
Medically Unlikely Edits
Medically Unlikely Edits (MUEs) are updated every quarter to prevent overbilling or incorrect billing. An MUE sets the maximum number of units for a HCPCS/CPT code that can be billed for one patient on the same date of service. These edits are available.
MUE units for HCPCS/CPT codes are determined by an MUE Adjudication Indicator (MAI), which specifies the type and rationle for each MUE. An MAI of “1” means the MUE is applied to each claim line, and modifiers 59, 76, 77, and 91 may be used to report additional 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: CMS Workgroup |
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 |
CPT code 11102 - |
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 |
These updates aim to streamline billing practices and help dermatologists avoid unintentional bundling errors. Visit the Academy’s Coding Resource Center for additional guidance and more coding resources.
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