National Correct Coding Initiative Procedure-to-Procedure (PTP) Edits
The Medicare National Correct Coding Initiative (NCCI) 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 Procedure-to Procedure (PTP) edits. NCCI PTP 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 by the same provider for the same beneficiary on the same date of service are denied, unless an exception applies.
The NCCI tool provides steps you can take to prevent these NCCI PTP denials:
- Do the NCCI PTP edits apply to your service? 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.
- If NCCI PTP edits apply to your service, determine whether you have an exception to the NCCI edits as noted by the Modifier Indicator assigned to the code combination.
| 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. |
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, CPT modifier 59 and HCPCS modifiers XE, XS, XP and XU. Medicare will allow these on column one and column two codes to bypass the edit.
Note: Denials based on NCCI edits are based on incorrect coding rather than medical necessity; therefore, it is not appropriate to issue an Advance Beneficiary Notice of Noncoverage (ABN) to shift liability to the beneficiary.
The complete listing of NCCI PTP code pair edits are found in NCCI section of the CMS website.
The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents.
You may submit nonclaim specific inquiries about the NCCI program in writing via email to NCCIPTPMUE@cms.hhs.gov.
Please contact Palmetto GBA for claim specific inquiries regarding NCCI.