A. Is the CPT/HCPCS code pair bundled with a NCCI edit? Yes Not Sure
B. Do you know the indicator (0, 1, or 9) of the code pair? Yes No
B. Access the CMS Web site for National Correct Coding Initiative (NCCI) at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/PTP-Coding-Edits. Scroll to the bottom of the page and open the 'Physician CCI Edits' link located under 'Related Links.' A ZIP file will then open and you will be able to view open a text or Excel file. Open one of the files and search for your code, not the indicator. Is your code pair on the Mutually Exclusive Edit list? Yes No
B. Access the CMS Web site for National Correct Coding Initiative (NCCI) at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/PTP-Coding-Edits. Scroll to the bottom of the page and open the 'Physician CCI Edits' link located under 'Related Links.' A ZIP file will then open and you will be able to view open a text or Excel file. Open one of the files and search for your code, not the indicator.
Is your code pair on the Mutually Exclusive Edit list? Yes No
C. Is the indicator for the code pair 0? Yes No
Stop Here. The codes cannot be reimbursed separately. Submit only the Column I code.
D. Is the indicator for the code pair 9? Yes No
Stop Here. NCCI edits DO NOT apply to this code pair. The codes may be submitted separately.
E. The indicator code for the code pair must then be 1. The code pair may ONLY be submitted separately if the services were performed at different patient encounters or if they involve different anatomical sites. A modifier is required for separate reimbursement and documentation is required in the medical record to support exceptions to NCCI edits. Is the Column I code an Evaluation and Management (E/M) code? Yes No
E. The indicator code for the code pair must then be 1. The code pair may ONLY be submitted separately if the services were performed at different patient encounters or if they involve different anatomical sites. A modifier is required for separate reimbursement and documentation is required in the medical record to support exceptions to NCCI edits.
Is the Column I code an Evaluation and Management (E/M) code? Yes No
F. Is the Column I code a surgical procedure? Yes No
G. Is the Column II code a surgical procedure? Yes No
H. Were the surgical procedures performed at different patient encounters? Yes No
I. Did the subsequent surgery require a return trip to the operating room? Click here to view CPT Modifier 78 guidelines. Yes No
Submit the subsequent surgery with CPT modifier 78. Documentation in the medical record must support the use of this modifier.
J. Was the subsequent surgery unrelated to the initial surgery? Click here to view CPT Modifier 79 guidelines. Yes No
Submit the subsequent surgery with CPT modifier 79. Documentation in the medical record must support the use of this modifier.
Stop here. Submit only the Column I surgery. The Column II surgery cannot be reimbursed separately.
I. Were the surgical procedures performed on different anatomical sites? Click here to view CPT Modifier 79 guidelines. Yes No
Surgeries are unrelated. Submit the subsequent surgery with CPT modifier 79. Documentation in the medical record must support the use of this modifier.
Stop here. Submit only the column I surgery. The Column II surgery cannot be separately reimbursed.
H. Is the Column II code an E/M code? Yes No
I. Is the E/M code a separately identifiable service? Click here to view CPT Modifier 25 guidelines. Yes No
Submit the E/M service with CPT modifier 25. Documentation in the medical record must support the use of this modifier.
Stop here. The E/M service cannot be separately reimbursed from the surgery.
I. Is the Column II code a separately identifiable services? Click here to view CPT Modifier 59 guidelines. Yes No
Submit the service with CPT modifier 59. Documentation in the medical record must support the use of this modifier.
Stop here. The Column II code cannot be separately reimbursed from the Column I code.
G. Is the Column II code a diagnostic service (CPT code 7xxxx, 8xxxx, 9xxxx series)? Yes No
H. The code is OTHER than an E/M, surgical or diagnostic service. Is the Column II code a separately identifiable services? Click here to view CPT Modifier 59 guidelines. Yes No
H. Is the diagnostic service a separately identifiable service? Click here to view CPT Modifier 59 guidelines. Yes No
F. Is the Column II code a surgical procedure? Yes No
G. Is the E/M code a separately identifiable service? Click here to view CPT Modifier 25 guidelines. Yes No
G. Is the Column II code a separately identifiable services? Click here to view CPT Modifier 59 guidelines. Yes No
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.
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