Anesthesia Coding Alert

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Navigate the Nuances of NCCI PTP Edits With Ease

Published on Mon Oct 09, 2023

Exercise caution when using a modifier to break an edit.

Do you ever find yourself stumped when trying to interpret the most recent update of the Centers for Medicare & Medicaid Services’ (CMS’) National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edit pairs? Ever wonder why CMS produces this comprehensive listing? If you do, you aren’t alone.

So, we put together this handy guide chock full of expert advice in an attempt to answer those questions and help you use this valuable tool to improve your CPT^® coding accuracy. Read on for four helpful tips that’ll boost your NCCI PTP edits savvy.

Focus on Why NCCI PTP Edits Matter

“PTP edits were developed to promote national correct coding methods, to control improper coding leading to inappropriate payments for Medicare claims, and to prevent unbundling of services,” said Arlene Dunphy, provider outreach and education consultant at the Medicare Administrative Contractor (MAC) National Government Services (NGS) in the webinar, “The National Correct Coding Initiative and Medically Unlikely Edits.”

Or, as CMS explains it, the purpose “is to prevent improper payment when incorrect code combinations are reported” by assembling “code pairs that should not be reported together for a number of reasons” (www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/).

NCCI’s coding policies are based on the CPT^® manual, the HCPCS manual, national and local Medicare policies, and coding guidelines that national societies developed. PTP edit pairs, which are updated quarterly, are just one type of NCCI edit. There are also medically unlikely edits (MUEs) and add-on codes.

Puzzle Out How PTP Edits Work

CMS creates an edit pair when it regards a specific service as being a component part of a larger, more comprehensive service. In PTP edits, when your provider submits two bundled codes, the Column 1 code is eligible for payment, but Medicare will deny the Column 2 code unless both codes are clinically appropriate, according to Dunphy. Also, your provider must include supporting documentation in the medical record.

NCCI does not include all possible code combinations, so providers are obligated to code correctly, even if edits do not exist, Dunphy said. Services that are denied based on PTP code pair edits may not be billed to Medicare beneficiaries, and you cannot utilize an advance beneficiary notice (ABN) to seek payment.

Pinpoint Different Modifier Indicators

CMS designates Column 1 status to the comprehensive service and Column 2 status to a code they regard as being a component part of the Column 1 service.

Each PTP edit pair is assigned one of three modifier indicators: 0, 1, or 9. Take a look at what these indicators mean:

Indicator 0 – These codes should never be reported together by the same provider for the same beneficiary on the same date of service (DOS).
Indicator 1 – These codes may be reported together only in defined circumstances (identified on claims by a specific NCCI-associated modifier).
Indicator 9 – Not relevant. The edit was deleted.

Example: Code 64425 (Injection(s), anesthetic agent(s) and/ or steroid; ilioinguinal, iliohypogastric nerves) is a Column 2 code to 49491 (Repair, initial inguinal hernia, preterm infant … with or without hydrocelectomy; reducible), which means they are bundled together. However, since the modifier indicator for this PTP edit pair is 1, you may break the edit with an NCCI-associated modifier under certain circumstances.

Bottom line: When it comes to PTP edit pairs, the Column 1 code is payable, and the Column 2 code is a component code that is only payable if certain criteria are met, according to Dunphy.

Append NCCI-Associated Modifiers Appropriately

Modifier 59 (Distinct procedural service) is probably the most well-known modifier when it comes to PTP edits. However, modifier 59 is also a widely abused modifier that some may use just to bypass an edit, so make sure you append this modifier appropriately, Dunphy said.

Also, documentation is key when you are using modifiers. The supporting documentation must satisfy the criteria required.

“Only use this modifier if it [modifier 59] best describes the circumstances,” Dunphy added. You should never just use modifier 59 as a default modifier.

X{EPSU}modifiers: Modifiers XE (Separate encounter…), XS (Separate structure…), XP (Separate practitioner…), and XU (Unusual non-overlapping service…) are a subset of modifier 59, but they have not replaced modifier 59.

You should never report modifiers X{EPSU} together with modifier 59 on your claim, Dunphy said. You should just report one modifier or the other.

Here are some tips from Dunphy about appropriate use for modifiers 59 and X{EPSU}. Use modifier 59 or X{EPSU}:

For a different session or patient encounter, different surgery, different anatomical site, or separate injury or area of injury;
When the medical record documentation indicates two separate distinct procedures performed on the same day by the same physician; and
When there is no other appropriate modifier to use.

On the other hand, you should never use modifiers 59 or X{EPSU} under the following circumstances:

If the code combination does not appear in the NCCI edits;
You should not append these modifiers to an evaluation and management (E/M) service performed on the same date. In that case, you should look to an E/M modifier such as modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or … on the same day of the procedure or other service);
If the PTP edit has a modifier indicator of 0, you cannot use a modifier to break the edit;
If the medical record documentation does not support the separate and distinct status, you cannot use a modifier; or
If the provider performed the exact same procedure twice on the same day, you should instead look to modifiers 76 (Repeat procedure or service by same physician …) or 77 (Repeat procedure by another physician …).

Editor’s note: There are two types of PTP edits; those for physicians and those for hospitals. We only talked about the PTP edits that impact physicians in this article.