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NCCI Procedure-to-Procedure Lookup

The Medicare National Correct Coding Initiative (NCCI) (also known as CCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. At a national level, CMS identifies individual services that are components of more inclusive services using NCCI edits. NCCI edits are designed to promote correct coding and prevent improper payments by "bundling" component codes into the more inclusive code. Component services that are billed separately from the more inclusive service are denied, unless an exception applies.

Our NCCI tool provides steps you can take to prevent these NCCI denials:

  • First, know if NCCI edits apply to the services you are submitting. Search for coding pairs by entering your major procedure code. The search results show coding pair lists entitled Column I or Column II.
    • Codes are designated as Column I or Column II codes. Most of the time, the "parent" code is in Column I and component code in Column II. For some code pairs, the Column I and II codes are considered "mutually exclusive" and should not be reported together
    • If both codes from a Column I and II code pair are submitted, the Column I code may be reimbursed and the Column II code will not be reimbursed.
  • Second, if an NCCI edit applies to your services, determine whether you have an exception to the NCCI edits as noted by the Modifier Indicator assigned to the code combination. (No exceptions are allowed if the modifier indicator is 0.) There must be documentation in the patient's medical record to support all exceptions.

    Reminder: There must be documentation in the patient's medical record to support all exceptions. If you feel your documentation supports an allowable exception, you may use one of the NCCI-associated modifiers, modifiers 59, XE, XS, XP, and XU. Prior to July 1, 2019, the Multi-Carrier System (MCS) required that the modifiers be appended to the column two code of a PTP edit to bypass the edit. As of July 1, 2019, with the implementation of CR 11168External PDF, Medicare will allow modifiers 59, XE, XS, XP, or XU on column one and column two codes to bypass the edit. For additional information on modifiers, please visit the CGS Part B Modifier Finder Tool.

    • Note: denials based on NCCI edits are coding denials, not medical necessity denials; therefore, it is not appropriate to issue an Advance Beneficiary Notice of Noncoverage (ABN) to shift liability to the beneficiary.

Modifier Indicator

Explanation

0

Codes are always bundled; do not submit a modifier for exceptions

1

Exceptions may apply; submit the appropriate modifier. (Note: documentation is required in the patient's medical record.)

9

Not applicable. The code pair is no longer bundled and no modifier is needed for purposes of noting an NCCI exception.

The complete listing of NCCI PTP code pair edits are found in NCCI sectionExternal Website of the CMS website.

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