NCCI Modifiers

[andrewallenbruce]

• CMS FAQ
• Add-On Codes
• MUEs
• PTP Edits

The NCCI PTP edits and MUEs are usually updated at least quarterly.

NCCI Modifiers

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include:

• Anatomic: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
• Global Surgery: 24, 25, 57, 58, 78, 79
• Other: 27, 59, 91, XE, XS, XP, XU

It’s very important that NCCI PTP-associated modifiers only be used when appropriate. In general, these circumstances relate to separate patient encounters, separate anatomic sites, or separate specimens. (See subsequent discussion of modifiers in this section.) Most edits involving paired organs or structures (e.g., eyes, ears, extremities, lungs, kidneys) have NCCI PTP modifier indicators of “1” because the two codes of the code pair edit may be reported if performed on the contralateral organs or structures. Most of these code pairs should not be reported with NCCI PTP-associated modifiers when performed on the ipsilateral organ or structure unless there is a specific coding rationale to bypass the edit.

The presence of an NCCI PTP edit indicates that the two codes generally can’t be reported together unless the two corresponding procedures are performed at two separate patient encounters or two separate anatomic locations. Similarly, if the two corresponding procedures are performed at the same patient encounter and in contiguous structures in the same organ or anatomic region, NCCI PTP-associated modifiers generally shouldn’t be used.

Modifier 59 (MLN 1783722 (PDF)) may be used only if no other appropriate modifier describes the service. The article provides more information on the appropriate use of the 59 modifier.

Some Column One/Column Two correct coding edits would ever warrant the use of any of the modifiers associated with the NCCI PTP edits. These code pairs are assigned a correct coding modifier indicator (CCMI) of 0.

Claim line edits allow use of NCCI PTP-associated Modifier 91 to bypass them if one or more of the individual laboratory tests are repeated on the same date of service. The repeat testing must be medically reasonable and necessary and can’t be performed to “confirm initial results; due to testing problems with specimens and equipment or for any other reason when a normal, one-time, reportable result is all that is required.”