Knowledge Base Article

As I write this article, it is a beautiful day with warm temperatures and lots of sunshine – a hint that spring is on its way though the weather forecast includes a drop back to frigid temperatures in the next few days, a harsh reminder that Winter is not yet finished. The intermittent warmth has caused new plant growth and already my lawn needs mowing to control the weeds and errant grasses. Time to pull out the lawn mower or call the lawn service. If you use a lawn service, you would not want to pay them for cranking their lawn mowers in addition to paying them for cutting the grass. Cranking the lawn mower is an inherent part of the service. Years ago, Medicare realized they should not be paying separately for services inherent in another procedure or groups of procedures and “developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. CMS developed the NCCI coding policies based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.” (Medicare NCCI webpage)

The NCCI includes:

• Procedure-to-Procedure (PTP) Edits – The PTP Column One/Column Two Correct Coding Edit Table contains edits which are pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. However, if it is clinically appropriate to utilize an NCCI-associated modifier, both the column one and column two codes are eligible for payment.
• Medically Unlikely Edits (MUEs) - MUEs prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service (UOS) under most circumstances reportable by the same provider for the same beneficiary on the same date of service. The ideal MUE value for a HCPCS/CPT code is one that allows the vast majority of appropriately coded claims to pass the MUE.
• The NCCI Policy Manual for Medicare Services - A general reference tool that explains the rationale for NCCI edits.

As noted above, both codes in some PTP code pairs can be paid if reported with an applicable modifier. Each PTP code pair includes a modifier indicator that specifies if modifiers are allowed to by-pass the NCCI edit or not. A modifier indicator of “0” means you cannot add a modifier to that code pair to by-pass the edit, while an indicator of “1” means a modifier is allowed. Providers should NEVER append a modifier solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use. Generally, the use of modifiers is related to circumstances such as separate patient encounters, separate anatomic sites or separate specimens. Some of the more common modifiers for by-passing NCCI PTP edits are the 59 and associated XE, XS, XP, and XU modifiers. For years, the instructions have been that the modifier must be appended to the column two code of a PTP edit to bypass the edit. That was just confusing and required extra time and effort to verify which code of the pair was the “column two code.” Claims data sometimes showed that even the Medicare contractors couldn’t get it right and paid both codes even when the modifier was reported on the column one code. Finally, Medicare is addressing this issue and effective July 1, 2019, Medicare will allow modifiers 59, XE, XS, XP, or XU on column one and column two codes to bypass the edit as communicated in MLN Matters Article MM11168.

In related news, there is a new Medicare contractor for the NCCI program. On February 1, 2019, CMS awarded the NCCI contract to Capitol Bridge LLC. The transition of the contract from the incumbent contractor, CCS WP LLC/Correct Coding Solutions LLC, to Capital Bridge started on February 3, 2019, and will end on March 15, 2019.  An announcement of the new contract can be found on the Medicare NCCI webpage in the Downloads section.