What is the Medicare NCCI?

The Medicare NCCI promotes correct coding methodologies and controls improper coding leading to improper payment. Coding policies are based on coding conventions defined in the American Medical Association’s (AMA’s) Current Procedural Terminology (CPT) Manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, and/or current coding practice.

Before implementing NCCI edits, CMS shares all NCCI proposed edits for review and comment with the AMA, national medical and surgical societies, and other national health care organizations, including non-physician professional societies, hospital organizations, laboratory organizations, and durable medical equipment (DME) organizations.

Background: NCCI Edits

NCCI has 2 provider-type choices of Procedure to Procedure (PTP) code pair edits and 3 provider-type choices of Medically Unlikely Edits (MUEs).

PTP Code Pair Edits

PTP code pair edits are automated prepayment edits that prevent improper payment when you report certain codes together for Part B-covered services.

1. Hospital PTP Edits
   PTP edits apply to Types of Bills (TOBs) subject to the Outpatient Code Editor (OCE) for the Outpatient Prospective Payment System (OPPS). These edits apply to outpatient hospital services and other facility services including, therapy providers in Part B Skilled Nursing Facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech language pathology providers (OPTs), and certain claims for home health agencies (HHAs) billing under TOBs 22X, 23X, 75X, 74X, 34X.
2. Practitioner PTP Edits
   PTP code pair edits apply to physicians and Ambulatory Surgery Center (ASCs) claims.

MUEs

Medicare Administrative Contractors (MACs) and DME MACs use MUEs, to reduce the improper payment rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service (UOS) that you would report under most circumstances for a single patient on a single date of service. Not all HCPCS/CPT codes have an MUE.

1. Practitioner MUEs
   These edits apply to all claims you submit for physician.
2. Durable Medical Equipment (DME) Supplier MUEs
   These edits apply to claims you submit to DME MACs. (This file includes HCPCS A-B and E-V codes and HCPCS codes under the DME MAC jurisdiction.)
3. Facility Outpatient MUEs
   These edits apply to all claims for TOBs 13X, 14X, 85X Critical Access Hospitals (CAHs), and 087x Opioid Treatment Programs (OTPs).

MUE values aren’t usage guidelines. You should only report units of service (UOS) that are medically reasonable and necessary. MACs may select your claims for medical review even if you report UOS less than or equal to the MUE value for a code.

Modifiers

Modifiers consist of 2 alphanumeric characters. You should only apply modifiers to HCPCS/CPT codes if the clinical circumstances justify using them. You shouldn’t apply a modifier to a HCPCS/CPT code just to bypass an MUE or PTP code pair edit if the clinical circumstances don’t justify using it.

If the Medicare Program imposes restrictions on applying a modifier, you should only use the modifier to bypass a PTP code pair or MUE edit if the Medicare restrictions are fulfilled. You’ll learn more about modifiers on pages 10 and 11 of this booklet.

Add-On Codes

An Add-on Code (AOC) is a HCPCS/CPT code that describes a service that, with rare exception, a practitioner does in conjunction with another primary service. An AOC is rarely eligible for payment if it’s the only procedure you report.

For information about AOC edits, refer to Add-on Code Edits.

Why Would You Use the NCCI Webpage, Tables, and Manual?

Accurate coding and reporting of services are critical aspects of proper billing. A denial of services due to an MUE is a coding denial, not a medical necessity denial. You can’t bill a Medicare patient for a service denied based on PTP code pair edits or MUEs. It’s not appropriate to use an Advance Beneficiary Notice of Noncoverage (ABN) to shift liability to the Medicare patient for UOS denied based on an MUE or coding denial. The tools on the NCCI webpage, including the NCCI Policy Manual for Medicare, will help you avoid coding and billing errors and resulting payment denials.

You’re subject to the statutory requirements found in section 1128J(d) of the Social Security Act and could face potential False Claims Act (FCA) liability, Civil Monetary Penalties Law (CMPL) liability, and exclusion from federal health care programs if you don’t report and return an overpayment.

For more information on overpayments, refer to the Medicare Overpayments Fact Sheet.

How Up to Date are the NCCI Tables?

CMS updates the NCCI Edits webpage with the most recent NCCI tables on a quarterly basis.

Select the Quarterly PTP and MUE Version Update Changes link in the left navigation menu of the NCCI Edits webpage to find quarterly changes to the PTP and MUE tables.

How to Find the NCCI Tables and Manual

You can access the NCCI Policy Manual, MUEs, and PTP edits through NCCI Edits webpage.

Links to the PTP Coding Edits, MUEs, and NCCI policy manual webpages are in the menu on the left side of the NCCI Edits webpage.

Using the NCCI Tools

Looking up PTP Code Pair Edits

Your first step in looking up an edit is to choose the PTP Coding Edits link in the menu on the left side of the National Correct Coding Initiative Edits webpage on the CMS webpage.

Figure 1 shows the screen after selecting PTP Coding Edits. Scroll to the Related Links section at the bottom of the page to find links to the Hospital PTP Edits tables and the Practitioner PTP Edits tables.

We’ll refer to the tables in Figure 1.2 as Hospital PTP Edits Table 1, Hospital PTP Edits Table 2, Hospital PTP Edits Table 3, Hospital PTP Edits Table 4, Practitioner PTP Edits Table 1, Practitioner PTP Edits Table 2, Practitioner PTP Edits Table 3, and Practitioner PTP Edits Table 4.

The names of the Hospital PTP Edits or Practitioner PTP Edits show the code range of edits listed in the table, beginning with the first Column 1 or Column 2 code edit in the file and ending with the last Column 1 or Column 2 code edit in the file. Column 1 CPT codes, which end with letters M, U, or T, appear in the first table for both Hospital PTP Edits and Practitioner PTP Edits. Column 1 HCPCS Level II codes, which begin with letters A-V appear in the last table for both Hospital PTP Edits and Practitioner PTP Edits.

Click on the Hospital PTP Edits or Practitioner PTP Edits table you want to view or save.

A license agreement will appear. To continue to the table, accept the terms and conditions of the AMA copyright.

You can open the tables in Microsoft Excel (the file ending in xlsx) or text file format.

How to Use the PTP Code Pair Tables

The Column 1/Column 2 Correct Coding edit tables contain PTP code pairs. We’ll show you how to use the PTP code pair tables, using code 99215 and 2 of the 4 Practitioner PTP Edits tables as our examples. Our examples show the following:

• When a code is the reimbursable code of a PTP code pair
• How to find all PTP code pairs when a code isn’t reimbursable or when it’s only reimbursable with appropriate use of a modifier
• When a modifier may be used

What are the Column 1/Column 2 PTP Code Pair Tables?

Although the Column 2 code is often a part of a more comprehensive Column 1 code, this relationship isn’t true for many edits. In some edits, the PTP code pair edit consists of 2 codes that you shouldn’t report together, unless you use the proper modifier.

For example, you shouldn’t report a vaginal hysterectomy code and total abdominal hysterectomy code together. You shouldn’t report many procedure codes together because they’re mutually exclusive of each other. You shouldn’t report mutually exclusive procedures at the same anatomic site or same patient encounter.

• An example of a mutually exclusive situation is the repair of an organ that you can perform by 2 different methods. You can only report 1 code of the 2 organ repair codes in a code pair.
• A second example is a service that you can report as an initial service or a subsequent service. Except for drug administration services, a provider can’t report an initial service and a follow-up service during the same patient encounter. For example, a provider should not report skilled nursing facility evaluation and management service 99304 (Initial Nursing Facility Care, per day) and 99307 (Subsequent Nursing Facility Care, per day) together on the same day for the same patient by the same practitioner.

To reduce the amount of claims denied for sex procedure edits, use the KX modifier to show services for transgender, ambiguous genitalia, and hermaphrodite patients. If a gender procedure edit conflict occurs, the KX modifier alerts the MAC that it isn’t an error and allows the claim to continue processing.

When is a Code the Reimbursable Code of a PTP Code Pair?

The Column 1/Column 2 Correct Coding edit tables have PTP code pairs. If you submit the 2 codes of an edit pair for payment for the same patient on the same date of service, the Column 1 code is eligible for payment and the Column 2 code is denied. But, if both codes are clinically appropriate and you use an appropriate NCCI-associated modifier, the codes in both columns are eligible for payment. Make sure your supporting documentation is in the patient’s medical record. For more information on using modifiers 59 and -X{EPSU}, see the Proper Use of Modifiers 59 & –X{EPSU} fact sheet.

To find when our example code 99215 is the reimbursable code of a PTP code pair, open the Practitioner PTP Edits Table containing edits from 61000/0213T-U0003/U0004 (or similar range) to search for 99215 in Column 1. You can use the Microsoft Excel filter tool to easily search for all instances of 99215 in Column 1 in the table. (The Filtering the PTP Data Tables section at the end of this booklet gives instructions for using the filter tool in Microsoft Excel.)

Figure 2 shows part of the Practitioner PTP Edits Table containing edits from 61000/0213T-U0003/U0004 (or similar range), with our example code 99215 in Column 1.

1. Column A shows the payable (Column 1) code.
2. Column B shows a Column 2 code that isn’t payable with this Column 1 code, unless an NCCI- associated modifier is permitted and submitted.
3. Column C shows the edit status before 1996.
4. Column D shows the effective date of the edit (year, month, date).
5. Column E shows the deletion date of the edit (year, month, date).
6. Column F shows if you can use a modifier. This number is the modifier indicator for the edit. (The Modifier Indicator Table, shown on page 11 of this booklet, gives more explanation.
7. Column G provides the category of the rationale for each PTP edit.

Our search shows part of the edit tables for Column 1/Column 2 PTP code pairs where 99215 is the payable code.

Figure 2 shows, you won’t be reimbursed for HCPCS code G0102 (Prostate cancer screening; digital rectal examination) with 99215 (Office or Other Outpatient Visit).

When is a Code the Column 2 Code of a PTP Code Pair?

Unlike the Column 1 search, you should search for Column 2 codes in all of the Practitioner PTP Edits tables. (Similarly, you would need to search all of the hospital tables.) Use the Microsoft Excel filter tool so all instances of a particular code are displayed in Column 2. (The Filtering the PTP Data Tables section on page 11 provides instructions for using the filter tool in Microsoft Excel.)

For example, code 99215 can appear in Column 2 of Practitioner PTP Edits tables.

If you filter Microsoft Excel for 99215 in Column 2 of the Practitioner PTP Edits Table containing edits from 0001A/0591T1-25999/96523 (or similar range), you’ll see that 99215 isn’t payable with 01462, Anesthesia for all closed procedures on lower leg, ankle, and foot.

If you filter for 99215 in Column 2 of the Practitioner PTP Edits Table containing edits from 61000/0213T- U0003/U0004 (or similar range), you’ll see that 99215 isn’t payable with 99221, Initial hospital care, unless you use an NCCI PTP-associated modifier.

How Do You Know When to Use a Modifier?

In the Correct Coding Modifier Indicators (CCMIs) column, the indicator 0, 1, or 9 shows whether an NCCI PTP-associated modifier allows the PTP code pair to bypass the edit. The following Modifier Indicator Table provides a definition of each of these indicators.

Hospital (Outpatient hospital and other facility) PTP Edits:

• Hospital PTP code pair tables work the same as the practitioner PTP code pair tables
• Modifiers and coding pairs may differ from the practitioner PTP code pair tables because of differences between facility and professional services

Filtering the PTP Data Tables

The fastest and most accurate way you can search any of the edit tables for a particular value is by using the Excel Filter feature

Note: We wrote the Filter tool instructions for Excel 2010. If you’re using an earlier version of Excel or another spreadsheet program, the Filter function might work differently. Use the Help feature of your program if you need help.

In the figures below, our example uses the Filter to search for instances of CPT code 99215 in Column 2 of the Practitioner PTP Edits Table 1. These instructions also can be used to filter Column 1 codes in any of the 4 PTP code pair tables.

Open the file in Excel format (.xlsx). Figure 3 shows you how to begin filtering. Choose the Column 2 heading and then choose Data and Filter.

Excel displays a dropdown arrow on each column header.

Select the dropdown arrow in Column 2. Excel will automatically highlight all values in the column. Choose the check box next to Select All to remove this default. Scroll down to the code you want.

Figure 4 shows Column 2 selected and a sort for 99215 you choose by clicking on the box beside this code. Next, click on OK.

Figure 5 shows a sample of occurrences of 99215 in Column 2 of the Practitioner PTP Edits Table 1.

When you’re done looking at the records filtered by the code you want, select on the filter symbol in the column you filtered, and select Clear Filter from Column 2 as shown in Figure 6. You should return to viewing all records before you can filter for a different value. When you’re done looking for records, you can remove the Filter by selecting Data and Filter.

Looking Up MUEs

An MUE for a HCPCS/CPT code is the maximum UOS you would report under most circumstances for a single patient on a single date of service.

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

All claims submitted to MACs, DME MACs, and outpatient facility services claims (Types of Bill 13X, 14X, 85X) are tested against MUEs. Since MUEs are coding edits, rather than medical necessity edits, claims processing contractors may have UOS edits that are more restrictive than MUEs. In those cases, the more restrictive claims processing contractor edit will apply to the claim. Similarly, if the MUE is more restrictive than a claims processing contractor edit, the more restrictive MUE will apply. You should only report services that are medically reasonable and necessary.

To view the tables of MUEs, choose Medically Unlikely Edits from the menu on the left side of the National Correct Coding Initiative Edits webpage. Scroll to the bottom of the page and choose the link to the table you want to review in the Downloads section.

Figure 7 shows the MUE tables for Practitioner Services, Facility Outpatient Hospital Services, and DME Supplier Services in the Downloads section. Links to MUE tables for the current and previous quarter are available.

Figure 8 shows a section of the Practitioner Services MUE table after selecting the Microsoft Excel format.

1. Column A titled HCPCS/CPT Code shows codes with an MUE value.
2. Column B titled Practitioner Services MUE Values shows the maximum UOS that you would report under most circumstances for a single patient on a single date of service.
3. Column C titled MUE Adjudication Indicator (MAI) describes the level of adjudication of the MUE
   • MAI 1 indicates a value adjudicated by claims processing systems at the claim line level.
   • MAI 2 indicates an absolute date of service edit based on policy, such as anatomic considerations, definition of the code, or published CMS policy.
   • MAI 3 indicates a value adjudicated by claims processing systems at the date of service level. If claim denials based on these edits are appealed, MACs may pay UOS in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units. MM8853 has more information on MAIs. Note: MAIs aren’t coding modifiers.
4. Column D titled MUE Rationale provides the category of rationale for each MUE.

Using the NCCI Policy Manual for Medicare

The NCCI Policy Manual for Medicare is available as a reference tool for correct coding and to explain the rationale for NCCI edits. Each chapter corresponds to a separate section of the CPT Manual, except:

● Chapter 1 has general correct coding policies

● Chapter 12 discusses HCPCS Level 2 codes

● Chapter 13 discusses Category III CPT codes

Each chapter is subdivided by topic to allow easier access to a particular code or group of codes. The introduction or narrative of any chapter doesn’t override Medicare policy.

The Introduction and Chapter 1 of the manual are excellent resources for basic information about proper coding practices and coding edits. Chapter 1, General Correct Coding Policies, discusses general coding principles, issues, and policies. Later chapters discuss many of these principles, issues, and policies in more detail with specific groups of HCPCS/CPT codes.

The manual uses examples to clarify principles, issues, or policies. The principles, issues or policies can apply to other codes beyond those used in examples. It’s also recommended that you review the chapters of the manual that relate to the code ranges you bill most often. These chapters include detailed information about correct coding and using NCCI-associated modifiers for separately reportable services.

The NCCI Program updates the NCCI Policy Manual for Medicare annually. You can find the NCCI Policy Manual using the link in the left navigation menu on the NCCI Edits webpage.

Need More Information?

Because MACS handle NCCI edits as part of routine claim processing, send your claim-specific questions to the MAC. Find your MAC’s website. This includes appeals of your NCCI-related claim denials.

The NCCI contractor can answer questions and concerns about NCCI edits and the program in general. Email questions about the NCCI program, including those related to NCCI edits (PTP, MUE, and AOC) to NCCIPTPMUE@cms.hhs.gov.

Resources

• Add-on Code Edits
• CMS HCPCS- General Information
• CMS Help with File Formats and Plug-Ins
• CMS Outpatient Code Editor (OCE)
• CMS Quarterly Provider Updates Electronic Mailing List
• Federal Register, Medicare Program; Reporting and Returning of Overpayments
• Medicare Claims Processing Manual
• MM8853 - Revised Modification to the Medically Unlikely Edit (MUE) Program
• NCCI FAQs
• NCCI Policy Manual for Medicare
• Proper Use of Modifiers 59 & –X{EPSU}
• Quarterly PTP and MUE Version Update Changes
• The National Correct Coding Initiative in Medicaid

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