Modifiers and the NCCI edits
Modifiers and the NCCI edits: In a nutshell
- There are two distinct tables included in the National Correct Coding Initiatives (NCCI) that play an essential role in modifier usage; Procedure-to-Procedure (PTP) and Medically Unlikely Edits (MUE).
- Consult the NCCI PTP edits to determine when and which procedure code needs modifier 59.
- Modifier 59 ensures appropriate payment for distinct, independent services performed by a single provider in one day
- Consult the NCCI MUE edits to determine when a code needs modifier 76
- Modifier 76 indicates to the payer that multiple units of the same exact procedure (CPT code) were provided subsequent to the original procedure on the same day.
The Centers for Medicare & Medicaid Services (CMS) allows you to bill two procedures done on the same day separately if they are on two different anatomical sites. Which modifiers apply depends on the code combination and the NCCI edits.
Procedure-to-Procedure Edits
The NCCI PTP table lists pairs of codes that should not be billed together unless both are for medically appropriate services. In such a case, you would need to add modifier 59 to indicate that both services were distinct and independent of each other. Otherwise the payer will bundle the procedures and deny reimbursement for one of the procedures.
However, you can’t apply modifier 59 to just any code. Along with listing the codes that can’t be paired together unless medically necessary, the NCCI indicates which code pairs require a modifier when reported in a particular scenario.
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Medically Unlikely Edits
Sometimes, modifier 59 isn’t enough to ensure that you get the appropriate reimbursement. Medically Unlikely Edits (MUE) identify the maximum number of units of the same CPT code that can be reported for a patient on the same date of service.
In dermatology, sometimes more than one unit of the same procedure is performed by the same dermatologist for the same patient on the same day. When both procedures are reported with the exact same CPT code, check the MUE tables to determine the maximum number of units allowed for that procedure code.
For example, let’s say you excise two lesions of the same exact size, one on the cheek and one on the nose, and report the same exact CPT code for each. If you try to bill for both procedures either on separate lines or with two units, your Medicare contractor is likely to reject the second excision as a duplicate, on the basis that you have exceeded the maximum units allotted for that code. In this situation, Medicare might not consider modifier 59 enough to override the rejection.
Using modifier 76 — repeat procedure or service by same physician or other qualified health professional — in place of modifier 59 for the secondary procedure could make it payable. Check with your payer before submitting the claim.
You can test your knowledge of modifier coding by taking a short Academy quiz, or see other coding quizzes.
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