Reason Code W7040

Published 10/10/2016

Outpatient Code Editor (OCE) has identified a component of a comprehensive procedure reported on same date of service.

  • Code 2 of a National Correct Coding Initiative (NCCI) code pair
  • Procedures could possibly be billed together if a modifier is present on one of the procedures

National Correct Coding Initiative (NCCI) is developed to prevent inappropriate payment of services that should not be reported together. It contains codes that are not separately payable except under certain circumstances. All claims processed against NCCI tables.  There are two NCCI Edit Types:

  • Column 1/Column 2 correct coding edits
    • One service is an integral part of other
    • Should not be billed together for other reasons (i.e. misuse of the code)
  • • Mutually Exclusive Edits
    • Code pairs that, for clinical reasons, are unlikely to be performed on the same patient, on the same day

Each code pair is assigned a modifier indicator:

  • 0 = No modifiers allowed to be used
    • If a code pair has a '0' indicator - There are no circumstances under which both procedures of code pair should be paid
  • 1 = Modifiers associated with NCCI may be used when appropriate
    • If a code pair has a '1' indicator - Modifier should be applied to Column 2 code to allow payment
  • 9 = NCCI Edits do not apply to this code pair or have been deleted

Review Hospital Outpatient Perspective Payment System (OPPS) NCCI edits (Addendums A and B), compare the services and append an appropriate modifier, if applicable. 

Note: If an adjustment needs to be submitted to correct billing errors on a rejected line item, then each applicable line item needs to be deleted and rekeyed in its entirety in order for the previous edit to be deleted. When adding or deleting a line, manually calculate the total charges on 0001 revenue code line.

When deleting & rekeying a revenue code line:

  • Enter 'D' on revenue code line being deleted
  • Press 'Home' key
  • Press 'Enter' key; entire line deletes & lines are resorted
  • Rekey revenue code line just below 0001
  • Press 'Enter' key & lines are resorted

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