Updates to the 2015 CCI Manual

on Monday, 08 December 2014. All News Items | Coding

Medicare’s Commandments – Thy Shall Not…

The Centers for Medicare and Medicaid Services (CMS) pay hospitals, physicians, and others for the Medicare services they provide, but not without a lot of detailed instructions on what providers should and shouldn’t do. Medicare has way more than ten commandments and in fact, the NCCI manual is full of them and seems to add more each year.

Medicare established National Correct Coding Initiative (NCCI or just CCI) edits to prevent unbundling of services and the ensuing overpayments. The CCI edits define code pairs that generally should not be reported together because the second code describes a subset of the work of the first code.   Originally established for physician billing, CCI edits now apply to both physicians and hospitals with some differences. There are separate edit tables for physicians and hospitals (edit tables are updated quarterly) but just one NCCI Policy Manual for Medicare Services that is updated annually. The CCI edit tables are located in the related links section of the NCCI Coding Edits webpage and the Policy Manual is available in the downloads section on the NCCI webpage.

Beginning in the January 2015, additional hospital and physician NCCI edit files have been provided which contain an edit rationale column.   These files, labeled as “NTIS format” are formatted to match the files previously supplied by NTIS.  For future releases, Medicare will consolidate the files into a single format. This additional rational information may be helpful in determining when a procedure is separate and distinct. The rationales in the new “edit rational column” include the following:

  • Anesthesia service included in surgical procedure
  • CPT "separate procedure" definition
  • CPT Manual or CMS manual coding instruction
  • HCPCS/CPT procedure code definition
  • Misuse of column two code with column one code
  • More extensive procedure
  • Mutually exclusive procedures
  • Sequential procedure
  • Standard preparation / monitoring service
  • Standards of medical / surgical practice

The NCCI Policy Manual provides discussion of the overall general reasoning of CCI edits and additional information or rationale about particular edits. I encourage all providers to be familiar with the NCCI Policy Manual. Some of the more interesting updates for 2015 are discussed below.

Modifier 59

Chapter 1, General Correct Coding Policies, provides some new guidance and examples of the use of Modifier 59 and discussion of the new X {ESPU} modifiers. More specific guidance is given for reporting diagnostic procedures that precede or follow a surgical or therapeutic procedure. The diagnostic procedure may be considered separate and distinct if it:

  • Occurs before/after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled with services that are required for the therapeutic intervention
  • It does not constitute a service that would have otherwise been required during the therapeutic intervention
  • And for diagnostic procedures before the therapeutic procedure, it clearly provides the information needed to decide whether to proceed with the therapeutic procedure

If the diagnostic procedure is an inherent component of the surgical or non-surgical therapeutic procedure, it should not be reported separately.

With the creation of the new more specific modifiers, I had wondered how it would be appropriate to report rehabilitative procedures provided during the same session but in different time increments. This is addressed in the new manual: “There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two timed services are provided in time periods that are separate and distinct and not interspersed with each other (i.e., one service is completed before the subsequent service begins), modifier 59 may be used to identify the services.”

There is also a long discussion in Chapter One concerning Medically Unlikely Edits (MUEs) and the new MUE Adjudication Indicators.

Closed Treatment of Fractures

Chapter 4 contains new guidance regarding what you can and can’t report for closed treatment without manipulation.  “If multiple closed fractures occur in an area that would have been treated with a single cast, strapping, or splint, only one CPT code for closed fracture treatment without manipulation may be reported.” This implies, for example, that if you are treating multiple metacarpal fractures in a closed treatment without manipulation, which could have been treated with a single cast, only one CPT code can be reported.

Endoscopic Dilation of Strictures

Chapter 6 contains this statement: “Gastrointestinal endoscopy CPT codes describing dilation of stricture(s) (e.g., CPT codes 43213, 45340, 45386) include dilation of all strictures dilated during the endoscopic procedure. These codes should not be reported with more than one (1) unit of service if more than one stricture is dilated.” Note that this is contradictory to the CPT instructions that state, “For transendoscopic balloon dilation of multiple strictures during the same session, report 43213 with modifier 59 for each additional stricture dilated.”

Eye Injections

Chapter 8 contains several new instructions concerning eye procedures including the two following:

  • “Injection of an antibiotic, steroid, and/or nonsteroidal anti-inflammatory drug during a cataract extraction procedure (e.g., CPT codes 66820-66986) or other ophthalmic procedure is not separately reportable. Physicians should not report CPT codes such as 66020, 66030, 67028, 67500, 67515, or 68200 for such injections.”
  • “CPT codes 64400-64530 describe injection of anesthetic agent for diagnostic or therapeutic purposes, the codes being distinguished from one another by the named nerve and whether a single or continuous infusion by catheter is utilized. All injections into the nerve including branches described (named) by the code descriptor at a single patient encounter constitute a single unit of service. For example, if a physician injects an anesthetic agent into multiple areas around the sciatic nerve at a single patient encounter, only one UOS of CPT code 64445 (injection, anesthetic agent; sciatic nerve, single) may be reported. “

Post-localization Mammography

Guidance for post procedure mammography following localization has been modified in Chapter 9 for the third year in a row. This year stereotactic guidance is added – “If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with mammographic or stereotacticguidance (e.g., 19081-19082,19281, 19282), the physician should not separately report a post procedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.”

Testing Validity of Drug Screen Specimen

Chapter 10 adds instructions that testing to assure the validity of a drug screen specimen is not separately billable: “Providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed. The Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 16 (Laboratory Services), Section 10 (Background) indicates that a laboratory test is a covered benefit only if the test result is utilized for management of the beneficiary’s specific medical problem. Testing to confirm that a urine specimen is unadulterated is an internal control process that is not separately reportable.”

Units of Chemodenervation Guidance

And lastly Chapter 11 explains limits on the units of service for chemodenervation guidance: “CPT code 95873 describes electrical stimulation for guidance in conjunction with chemodenervation, and CPT code 95874 describes needle electromyography for guidance in conjunction with chemodenervation. During a patient encounter only one of these codes may be reported with a maximum of one (1) unit of service for guidance in conjunction with chemodenervation regardless of the number of muscles chemodenervated.”

There is a lot more new text in the updated NCCI Policy Manual – new text in the manual chapters is highlighted in red italics so it is easy to find. I recommend you at least scan any chapters that apply to your area of interest for updated guidance for what you ‘shall not do…”

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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