NATIONAL CORRECT CODING

INITIATIVE (NCCI) EDITS

Will CMS pay separately for multiple code if I bill together ???
 Will CMS pay separately for multiple code if I bill together ???

● On the SAME Date of Service?

● For the SAME patient?
● By the SAME Provider?
 Will CMS pay one service if I bill multiple times ???

● On the SAME Date of Service?

● For the SAME patient?
● By the SAME Provider?
What is the National Correct Coding Initiative?

• NCCI edits consist of a list of bundled CPT codes that give information about what codes cannot be billed
together in outpatient encounters
• CMS designed to limit coding errors that lead to incorrect Medicare payments
• CMS updates the NCCI Policy Manual for Medicare Services periodically based on current recommendations
from the American Medical Association (AMA) and other local and national stakeholders
• Not all codes are assigned a NCCI edit.
Types of NCCI Edits

1. Procedure to procedure (PTP) edits

2. Medically unlikely edits (MUE)
3. Add-on code edits
How to get NCCI Edits
PROCEDURE TO PROCEDURE (PTP) EDITS
• PTP edits define pairs of Healthcare Common Procedure Coding System (HCPCS) /Current Procedural Terminology (CPT)
codes that should not be reported together for a variety of reasons.
• PTP edits, delivered as a mutually exclusive CPT code list, prevent facilities from receiving reimbursement for service codes
that cannot be used together
• The PTP edits prevent improper payments when incorrect code combinations are reported.
• PTP edit tells you to bill when there are pairs of CPT/HCPCS codes under the below circumstances :
• Yes you can bill it together
• No You cannot bill it together
• May be you can bill it together

• PTP has 2 tables

• Table 1: Hospitals: Outpatient perspective payment system (OPPS)
• Table 2 : Practitioners: (pro fee services), physicians, and Ambulatory Surgery Center (ASCs) claims
Application of PTP edits

• Each PTP edit consists of two columns, each with one of two codes that comprise the pair.
• Medicare will pay for the code in column 1 and deny the code in column 2 when they are reported for the
same client on the same date.
• PTP codes often have an indicator as follows:
• 0 means the provider can never use a modifier with the code in question
• 1 means the provider can use an appropriate modifier to distinguish between the services in the code edit pair
• 9 means the code pair has been deleted and edits no longer apply, eliminating the need for a modifier
Scenario 1
HPI : A 45-year-old woman presents to her primary care physician with a new lump in her right breast that she noticed during a self-exam.
She reports that the lump is painless and has been present for about a month. She denies any nipple discharge, skin changes, or breast
pain. She has no personal or family history of breast cancer.
Physical examination: The patient has a palpable, firm mass in the upper outer quadrant of her right breast. The mass is non-tender and
measures about 2 cm in diameter. There are no palpable lymph nodes in the axilla or supraclavicular areas. A mammogram and
ultrasound of the breast confirm the presence of a suspicious mass that requires further evaluation with a breast biopsy..
Radiology Orders :
76942-Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and
interpretation
77002- Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)
Column 1: 76942-Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and
interpretation

Column 2:
77002 - Fluoroscopic guidance for needle placement
77003 - Fluoroscopic guidance for central venous access device placement, replacement
77012 - Computed tomography guidance for needle placement
77021 - Magnetic resonance imaging guidance for needle placement
77031 - Stereotactic localization guidance
77032 - Image-guided fluid collection drainage by catheter
Scenario 2
HPI : A 50-year-old male presents to the emergency department with a complaint of severe knee pain that has been progressively
worsening over the past few days. He reports that the pain is located on the front and inside of his left knee, and is aggravated by
movement, weight-bearing, and even at rest. He denies any recent trauma or injury to the knee, but reports a history of
osteoarthritis in both knees.
Physical Examination: The patient's left knee is swollen, warm, and tender to palpation. There is limited range of motion due to
pain, and he is unable to fully extend or flex the knee. There is no obvious deformity or erythema. The patient has a fever of 101°F
and an elevated white blood cell count.
These signs and symptoms suggest a possible inflammatory condition of the knee joint, such as septic arthritis or gout.
Arthrocentesis of the knee would be a diagnostic and therapeutic option in this scenario, as it would allow for the analysis of
synovial fluid for signs of infection, inflammation, or crystal deposition. It would also provide relief from the pressure and pain
caused by the excess fluid buildup in the joint.

Plan : 20610 - Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial
bursa)
76942 - Ultrasonic Guidance For Needle Placement (Eg, Biopsy, Aspiration, Injection, Localization Device), Imaging Supervision
And Interpretation
Column 1 : 20610 - Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint,
subacromial bursa)

Column 2 : 76942 - Ultrasonic Guidance For Needle Placement (Eg, Biopsy, Aspiration, Injection, Localization Device),
Imaging Supervision And Interpretation
Scenario 3
HPI : A 35-year-old woman presents to an otolaryngologist with complaints of chronic nasal congestion, difficulty breathing through her nose, and
recurrent sinus infections. She reports that she has a history of nasal trauma and has noticed a persistent deviation of her nasal septum that has
worsened over time. She also reports occasional nosebleeds and snoring at night. She has tried over-the-counter nasal sprays and allergy medications
without relief.
Physical Examination: The patient has a visibly deviated nasal septum that is obstructing the left nasal cavity. The nasal turbinates, which are bony
structures that project into the nasal cavity, are swollen and congested. There is no evidence of nasal polyps or sinus masses. A CT scan of the sinuses
confirms the presence of a deviated septum and mild sinusitis.
Plan : Impaction of cerumen in the left ear is diagnosed ,that is causing hearing loss and discomfort. Removal of the impacted cerumen would be a
treatment option

Orders :
30520 - Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft
92504 - Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue
volume reduction); superficial
Column 1 : 30520 - Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft
Column 2 : 92504 - Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency
ablation, or tissue volume reduction); superficial
Scenario 4

HPI : A 60-year-old man presents to the emergency department with complaints of persistent cough, shortness of breath, and chest pain. He
reports that he has a history of smoking and has been experiencing these symptoms for the past few days. He also reports feeling feverish and
fatigued.
Physical Examination: The patient appears ill and is breathing rapidly. He has a temperature of 101°F and his oxygen saturation level is low. Lung
auscultation reveals crackling sounds in the lower lobes of both lungs. His heart sounds are normal, and there is no evidence of peripheral
edema or cyanosis..
Plan : Chest x-rays were ordered in view of respiratory infection, such as pneumonia or bronchitis, in the patient.

Orders :
71046 - Radiologic examination, chest; 2 views
92504 - Radiologic examination, chest; single view
Scenario 5

HPI : A 50-year-old woman presented for a routine check-up. She reports feeling generally well but has a family history of heart disease and is
concerned about her own risk factors. She denies any chest pain, shortness of breath, or other cardiovascular symptoms.
Physical Examination: On physical examination, the patient's blood pressure is within normal limits, and her heart rate and rhythm are regular.
There are no significant findings on lung or abdominal examination. However, she is overweight with a body mass index of 30 and has central
obesity with a waist circumference of 38 inches.
Plan : These signs and symptoms indicates increased risk of cardiovascular disease in the patient, which could be further assessed through a
lipid panel.
Orders :
80061 - Lipid panel this panel must include the following: cholesterol, serum, total (82465), lipoprotein, direct measurement, high density
cholesterol (hdl cholesterol) (83718), triglycerides (84478)
82465 - cholesterol, serum, total
83718 - lipoprotein, direct measurement, high density cholesterol (hdl cholesterol)
84478 - triglycerides
80061 - Lipid panel this panel must include the following: cholesterol, serum, total (82465), lipoprotein, direct
measurement, high density cholesterol (hdl cholesterol) (83718), triglycerides (84478)
82465 - cholesterol, serum, total
83718 - lipoprotein, direct measurement, high density cholesterol (hdl cholesterol)
84478 - triglycerides
Scenario 6

HPI : A 45-year-old male patient presents to the orthopedic clinic complaining of persistent pain and difficulty with weight-bearing in his right
leg for the past 2 years. He reports that he had a fracture in his right tibia after a motor vehicle accident 2 years ago, which was initially treated
with casting and immobilization. Despite following the recommended treatment plan, the patient continued to experience pain and difficulty
with walking.
Upon examination, the orthopedic surgeon notes that the patient has a visibly shortened and angulated tibia with significant tenderness on
palpation. X-ray imaging reveals a nonunion of the tibia fracture with malalignment of the bone ends. The surgeon diagnoses the patient with a
nonunion and malunion of the tibia fracture and recommends surgical intervention.
The patient is scheduled for surgery to repair the nonunion and malunion of the tibia.

Orders :
27720 - Repair of nonunion or malunion, tibia; without graft, (eg, compression technique82465 - cholesterol, serum, total
12001 - Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5
cm or less
27720 - Repair of nonunion or malunion, tibia; without graft, (eg, compression technique82465 - cholesterol, serum, total
12001 - Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands
and feet); 2.5 cm or less
To select appropriate modifiers
Applicable Modifiers for PTP Edits

Anatomic Modifiers :
E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
Global Surgical Modifiers :
27, 59, 91, XE, XS, XP, XU
MEDICALLY UNLIKELY EDITS (MUEs)
• MUEs reject claims that include too many of the same service (or units of a timed service) for the same patient on the same day under the same
specialty.
• MUEs define, for each HCPCS/CPT code, the maximum Units of Service (UOS) that a provider would report under most circumstances for a single
beneficiary on a single date of service.
• Unlike PTP edits, which are available to browse on CMS’s website, many MUE values are confidential and only available for CMS and CMS contrac
to use or review
• CMS issues PTP and MUE code updates quarterly to reflect changes to evolving healthcare policy and research
• CMS develops MUEs based on:
● HCPCS/CPT code descriptors
● CPT coding instructions
● Anatomic considerations
● Established CMS policies
● Nature of service or procedure
● Nature of analyte
● Nature of equipment
● Prescribing information
● Clinical judgment
MNEC-005 Service/supply may be appropriate, but too frequent
28475 - Closed treatment of metatarsal fracture; without manipulation, each
26110 - Arthrotomy with biopsy; interphalangeal joint, each
10005 - Fine needle aspiration biopsy, including ultrasound guidance; first lesion
10080 - Incision and drainage of pilonidal cyst; simple
93000- Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
94640- Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum
induction for diagnostic purposes (eg, with an aerosol generator, nebulizer, metered dose inhaler or
intermittent positive pressure breathing [ippb] device)
(Nebulization)
MUE ADJUDICATION INDICATOR
MUE AI – 1 (1 Line Edit)

Claim line edit policy Don’t bill more than the MUE value on any given claim line
How to bill in excess of allowed MUE MAI 1

Use the below modifiers

76/77-
RT/LT
FA/F1-F9
TA/T1-T9
E1-E4
91 – lab services
59/X-EPSU -
MUE AI – 2 (2 Date of Service Edit: Policy)

Date of Service Edit: Policy Don’t bill more than the MUE value on the claim
(Per day codes)

• Absolute Criteria
• No appeal
• No modifier
• Based on Policy
MUE AI – 3 (3 Date of Service Edit: Clinical)

Claim line edit policy Don’t bill more than the MUE value on the claim,
UNLESS….

Appeal with Documentation

ADD ON CODE EDITS
Example 1 :
96360- Intravenous infusion, hydration; initial, 31 minutes to 1 hour- initial
+ 96361 – each additional hour
Example 2:
37248 – Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including
all imaging and radiological supervision and interpretation necessary to perform the angioplasty
within the same vein; initial vein
+37249- each additional vein
• CMS will update the complete list of AOC edits on an annual basis on or by Jan. 1 based on changes to
the CPT Manual or HCPCS Level II Manual.
• CMS may post quarterly updates on April 1, July 1, and Oct. 1 of each year.
• If CMS provides quarterly updates, they are complete files of AOC edits.
• If there are no changes in the AOC edits, then there is no quarterly update.
How to recognize ADD-OIN codes

• CPT code book marking + (use in conjunction with )

• HCPCS Code descriptor (list in additional to)
• Global Surgical days
• AOC edit table
 Types of Add on Codes

TYPE 1
A Type 1 AOC has a limited number of identifiable primary procedure codes. The Change Request (CR) lists the Type 1 AOCs
with their acceptable primary procedure codes. A Type 1 AOC, with one exception, is eligible for payment if one of the listed
primary procedure codes is also eligible for payment to the same practitioner for the same patient on the same date of
service. Claims processing contractors must adopt edits to assure that Type 1 AOCs are never paid unless a listed primary
procedure code is also paid.

Example 1 :
96360- Intravenous infusion, hydration; initial, 31 minutes to 1 hour- initial
+ 96361 – each additional hour
Example 2:
37248 – Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging
and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial
vein
+37249- each additional vein
TYPE 2
A Type 2 AOC does not have a specific list of primary procedure codes. The CR lists the Type 2 AOCs without any
primary procedure codes. Claims processing contractors are encouraged to develop their own lists of primary
procedure codes for this type of AOC. Like the Type 1 AOCs, a Type 2 AOC is eligible for payment if an acceptable
primary procedure code as determined by the claims processing contractor is also eligible for payment to the same
practitioner for the same patient on the same date of service.

No primary Codes – Contractor Defined Primary Code

TYPE 3
A Type 3 AOC has some, but not all, specific primary procedure codes identified in the CPT Manual. The CR lists the
Type 3 AOCs with the primary procedure codes that are specifically identifiable. However, claims processing
contractors are advised that these lists are not exclusive and there are other acceptable primary procedure codes
for AOCs in this Type. Claims processing contractors are encouraged to develop their own lists of additional
primary procedure codes for this group of AOCs. Like the Type 1 AOCs, a Type 3 AOC is eligible for payment if an
acceptable primary procedure code as determined by the claims processing contractor is also eligible for payment
to the same practitioner for the same patient on the same date of service..
 Add- on Code Edit Exception

99292 may be paid to a physician who does not report 99291

If

another physician of the same specialty (within the same group of practice) is paid for 99291 on
the same date of service
In Summary :

Type 1 – Specified base codes

Type 2 – Contractor defined base codes

Type 3 - Specified + contractor defined base codes

THANK YOU