Established Patient Office Visits: NCCI Bundling Denials

Denial Reason, Reason/Remark Code(s)

• M-80: Not covered when performed during the same session/date as a previously processed service for the patient
• CO-B15: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
• CPT code: 99211

National Correct Coding Initiative
The National Correct Coding Initiative (NCCI) packages or 'bundles' reimbursement for some services under Medicare. NCCI identifies code pairs that are never reimbursed separately and code pairs that can only be reimbursed separately in certain circumstances (identified by the appropriate modifier).

Resources

• Check NCCI edits prior to claim submission; edits are updated quarterly. NCCI edits are available on the CMS website.
• CPT code 99211 is bundled with many CPT codes
  • If CPT code 99211 is marked with indicator '0' in the NCCI edit list, it cannot be reimbursed separately from other procedures. Do not submit the service.
  • If CPT code 99211 is a separate, distinct service and is marked with indicator '1' in the NCCI edit list, submit CPT modifier 25 to denote it as a separate service
• Examples of separate, distinct services include situations in which the minimal office visit was performed a different patient encounter from the procedure with which it is bundled. Supporting documentation is required in the medical records.
• For additional, specific information on modifiers that may be used to denote exceptions to NCCI (including CPT modifier 25)