Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: March 10, 2020

Billing and Coding Advice

A.  How do I obtain billing and coding advice from the National Correct Coding Initiative (NCCI) Program?

The NCCI program contractor provides general information to the public regarding the NCCI program and edits. However, we do not provide specific billing or coding advice to providers/suppliers. Questions regarding specific claims should be addressed to your claims processing contractor (e.g., your Part A or B Medicare Administrative Contractor (MAC) or State Medicaid Agency). Providers/suppliers may also find it helpful to contact their national healthcare organization or the National Healthcare Organization (NHO) whose members commonly perform the procedure.

B.  What can I do about other commercial payers who deny payment citing NCCI edits?

Other government and private insurers may voluntarily choose to adopt Medicare's NCCI methodologies. The application of Medicare’s NCCI methodologies, and thereby the application of Medicare payment policies and rules, to claims other than Medicare Part B claims may result in denials by other plans. Plans that voluntarily choose to adopt Medicare's NCCI methodologies should review their edits and consider deactivating individual edits that conflict with their own benefit and coverage determinations. If you have questions or concerns regarding this process, please contact your payer directly.

NCCI Policy Manual

A. How do I obtain the NCCI Policy Manual?

The NCCI Policy Manual for Medicare Services may be obtained on the CMS NCCI webpage.

B. Where can I find information about the NCCI program in the Medicare manuals?

Information about the NCCI program can be found in the Internet-Only Manual, Publication 100-04, Section 20.9 of Chapter 23 of the Medicare Claims Processing Manual. (PDF)

Medically Unlikely Edit (MUE)

A. What is an MUE?

An MUE is a unit of service edit for a Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) code for services rendered by a single provider/supplier to a single beneficiary on the same date of service. The ideal MUE is the maximum unit(s) of service that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims.  MUEs are adjudicated either as claim line edits or date of service edits.  (See separate FAQ for guidance on reporting medically reasonable and necessary services in excess of an MUE value.) (See separate FAQ for information about date of service MUEs.)

B. How do I report medically reasonable and necessary units of service (UOS) in excess of an MUE value?

For MUEs that are adjudicated as claim line edits, each line of a claim is adjudicated separately against the MUE value for the code on that line.  The appropriate use of HCPCS/CPT modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary UOS in excess of an MUE value. Further information is available in MLN Matters MM8853.

C. Are there NCCI Medicare date of service MUEs and Claim Line MUEs for HCPCS /CPT codes?

There are both date of service and claim line MUEs.  The CMS publishes which codes have date of service and which codes have claim line MUEs.  For date of service MUEs, the claims processing system sums all UOS on all claim lines with the same HCPCS/CPT code and date of service. The MUE files on the CMS NCCI webpage display an “MUE Adjudication Indicator” (MAI) for each HCPCS/CPT code. An MAI of “1” indicates that the edit is a claim line MUE. An MAI of “2” or “3” indicates that the edit is a date of service MUE.  Further information is available in MLN Matters MM8853.

D. How are claims adjudicated with MUEs?

MUEs are either claim line edits or date of service edits.  If the MUE is a claim line edit, each line of a claim is adjudicated against the MUE value for the HCPCS/CPT code on that claim line.  If the UOS on the claim line exceeds the MUE value, all UOS for that claim line are denied.  If the same code is reported on more than one line of a claim by using CPT modifiers, each line of the claim is adjudicated separately against the MUE value of the code on that claim line.

If the MUE is a date of service MUE, all UOS for the HCPCS/CPT  code reported by the same provider/supplier for the same beneficiary for the same date of service are summed.  The summed value is compared to the MUE value.  If the sum is greater than the MUE value, all UOS for the code on the current claim are denied.

E. What is the Centers for Medicare & Medicaid Services (CMS) MUE program?

The CMS MUE program was developed to reduce the paid claims error rate for Medicare claims. MUEs are designed to reduce errors due to clerical entries and incorrect coding based on criteria such as anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established CMS policies, nature of a service/procedure, nature of an analyte, nature of equipment, prescribing information, and claims data.

F. What is the difference between the MUE tables for Outpatient Hospital (OPH) or Practitioner (PRA)?

There are separate MUE files, depending on the provider/supplier, for Practitioner use and Outpatient Hospital use. Further information may be found in the CMS NCCI “How to Use the NCCI Tools” document at the bottom of the NCCI webpage under downloads. This document may be found at the bottom of the NCCI webpage under downloads.

G. How often are the NCCI PTP edits and MUEs updated?

The NCCI PTP edit files and MUEs files are updated at least quarterly.

H. How do I know if a PTP edit is in effect?

The booklet “How to Use the National Correct Coding Initiative (NCCI) Tools (PDF)” provides more information regarding PTP edits.

NCCI PTP edits and MUEs for HCPCS/CPT codes apply to services reported by the same provider/supplier for the same beneficiary on the same DOS.

I. Has the CMS published the MUE values for HCPCS/CPT codes?

Most MUE values are visible to providers / suppliers on the NCCI webpage. However, some MUEs are considered confidential by the CMS and are not released. The public/confidential status of MUEs may change.

J. May an Advanced Beneficiary Notice (ABN) be used to bill the beneficiary for services denied due to a MUE?

ABN issuance based on an MUE is NOT appropriate.  A denial of services due to an MUE is a coding denial, not a medical necessity denial. The presence of an Advance Beneficiary Notice (ABN) shall not shift liability to the beneficiary for UOS denied based on an MUE. If during reopening or redetermination medical records are provided with respect to an MUE denial for an edit with an “MUE Adjudication Indicator” (MAI) of “3,” MACs will review the records to determine if the provider/supplier actually furnished units in excess of the MUE, if the codes were used correctly, and whether the services were medically reasonable and necessary. If the units were actually provided but one of the other conditions is not met, a change in denial reason may be warranted (for example, a change from the MUE denial based on incorrect coding to a determination that the item / service is not reasonable and necessary under section 1862(a)(1)). This may also be true for certain edits with an MAI of “1.” The CMS interprets the notice delivery requirements under Section1879 of the Social Security Act (the Act) as applying to situations in which a provider/supplier expects the initial claim determination to be a reasonable and necessary denial. Consistent with NCCI guidance, denials resulting from MUEs are not based on any of the statutory provisions that give liability protection to beneficiaries under section 1879 of the Social Security Act.  Thus, ABN issuance based on an MUE is NOT appropriate. Further information is available in MLN Matters MM8853.

K. How are MUEs developed?

MUEs are developed based on HCPCS/CPT code descriptors, CPT coding instructions, anatomic considerations, established CMS policies, nature of service / procedure, nature of analyte, nature of equipment, prescribing information, and clinical judgment. MUE values are not utilization guidelines and do not represent UOS that may be reported without concern about medical review. Providers should continue to only report services that are medically reasonable and necessary. Providers may be subject to medical review of their claims even if they report UOS less than or equal to the MUE value for a code.

L. How do I request a change in the MUE value for a HCPCS/CPT code?

If a provider/supplier, healthcare organization, or other interested party believes that a MUE value should be modified, they may email the CMS NCCI Mailbox at NCCIPTPMUE@cms.hhs.gov. The party should include, exact codes, an alternative MUE value, the rationale for the alternative MUE value and any supporting documentation.  **NOTE** Any submissions made to the NCCI contractor that contain Personally Identifiable Information (PII) or Protected Health Information (PHI) are automatically discarded, regardless of the content, in accordance with federal privacy rules with which the NCCI Contractor must comply.
However, it is generally recommended that the party contact the NHO whose members perform the procedure. The NHO may be able to clarify the reporting of the code in question. If the NHO agrees that the MUE value should be modified, its support and assistance may be helpful in requesting the modification of an MUE value.

M. How do I make an inquiry about the MUE program other than about MUE values for specific HCPCS/CPT codes?

All available MUE tables for Medicare for the most recent quarter are published on the CMS website.

N. What determines the Unit of Service for a Medically Unlikely Edit (MUE)?

Inquiries about the NCCI program, including those related to NCCI (PTP, MUE and Add-On Code) edits, should be sent to the following email address: NCCIPTPMUE@cms.hhs.gov.

O. What determines the Units of Service (UOS) for an MUE?

UOS are defined by the code descriptor (also referred to as the narrative description of the code).

Examples below show the HCPCS code, followed by the code descriptor, followed by the UOS: 

• J1100 “Injection, dexamethasone sodium phosphate, 1 mg” the unit of service is 1 mg
• J0670 “Injection, mepivacaine hydrochloride, per 10 ml” the UOS is 10 ml
• J7180 Injection, factor xiii (antihemophilic factor, human), 1 IU, the unit of service is 1 International Unit (IU)
• 99292 “Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes” the unit of service is 30 minutes

P. How do you correctly report bilateral procedures?

For more information on bilateral procedures, please refer to the CMS MLN Article SE1422, Medically Unlikely Edits (MUE) and Bilateral Surgical Procedures.

For more information, please reference The NCCI Policy Manual for Medicare Services, Chapter 1, Section V, available on the NCCI Medicare website.

Q. What does an MUE Adjudication Indicator (MAI) mean?

The MUE files on the CMS NCCI website display an MAI for each HCPCS/CPT code. An MAI of “1” indicates that the edit is a claim line edit. An MAI of “2” or “3” indicates that the edit is a date of service MUE.

The MLN article MM8853, found on the CMS website, may also answer some of your questions regarding MUEs / MAIs.

Procedure-to-Procedure (PTP) Edits

A. What does "Column 1" or “Column 2” mean in the Column 1 / Column 2 NCCI edits table?

Detailed instruction regarding the use of “Column 1” or “Column 2” may be found in the “How to Use the NCCI Tools” document. This document may be found at the bottom of the NCCI webpage under downloads.

B. How long are the PTP edits and MUEs in the NCCI program valid?

There is no set time period for which NCCI edits are valid.  Some edits may remain in place indefinitely. The PTP edits and MUEs may be updated at least quarterly.

C. Where is the effective date of a PTP edit?

The effective date of an edit will be listed in the PTP edit file.

D. Where can I find the rationale for why an edit is in place?

General information about edit rationale may be found in the NCCI Policy Manual, Chapter 1, available on the CMS NCCI webpage.

E. If each of the HCPCS/CPT coded procedures listed in the NCCI PTP edit is performed by 2 different physicians in my clinic, will both services be paid?

NCCI PTP edits for HCPCS/CPT codes apply to services reported by the same provider/supplier for the same beneficiary on the same date of service.

The NCCI program contractor provides general information to the public regarding the NCCI program and edits. However, we do not provide specific billing or coding advice to providers / suppliers and we do not deal with payment issues. Questions regarding specific claims should be addressed to your claims processing contractor (e.g., your Part A or B Medicare Administrative Contractor (MAC) or State Medicaid Agency).

F. How do NCCI edits apply to Critical Access Hospitals (CAHs)?

PTP edits are applied to Type of Bill “85X, and OPPS flag = 2” as explained in the narrative in the OCE Quarterly Release Files and in MLN article SE18012.

The booklet “How to Use the National Correct Coding Initiative (NCCI) Tools (PDF)” provides more information.

G How is the rationale for an edit assigned?

General information about edit rationale may be found in the NCCI Policy Manual, Chapter 1, available on the CMS NCCI webpage.

H. What steps can I take to ask CMS to reconsider a PTP edit?

If you would like to make a Medicare PTP reconsideration request, please email us at NCCIPTPMUE@cms.hhs.gov with exact code pairs, detailed reconsideration, new proposed edits, and any supporting documentation you have. **NOTE** Any submissions made to the NCCI contractor that contain Personally Identifiable Information (PII) or Protected Health Information (PHI) are automatically discarded, regardless of the content, in accordance with federal privacy rules with which the NCCI Contractor must comply.

I. Although a PTP edit has been deleted, there is a Correct Coding Modifier Indicator (CCMI) present in the field, what does this mean?

A deleted edit is one where no edit exists for that particular code pair. Therefore, when reporting these services, no modifier is required. A modifier Indicator of "9" means that an NCCI edit does not apply to this PTP code pair. The edit for this PTP code pair was deleted. In the current PTP edit tables, Column E shows the deletion date of the deleted code pairs and Column F shows the modifier status when the edit was active.

J. What does a Correct Coding Modifier Indicator (CCMI) mean?

The booklet “How to Use the National Correct Coding Initiative (NCCI) Tools” provides more information regarding PTP edits and CCMI.

NCCI Modifiers

A. What modifiers are allowed with the NCCI PTP edits?

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include:

Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
Global surgery modifiers: 24, 25, 57, 58, 78, 79
Other modifiers: 27, 59, 91, XE, XS, XP, XU

It is very important that NCCI PTP-associated modifiers only be used when appropriate. In general, these circumstances relate to separate patient encounters, separate anatomic sites, or separate specimens. (See subsequent discussion of modifiers in this section.) Most edits involving paired organs or structures (e.g., eyes, ears, extremities, lungs, kidneys) have NCCI PTP modifier indicators of “1” because the 2 codes of the code pair edit may be reported if performed on the contralateral organs or structures. Most of these code pairs should not be reported with NCCI PTP associated modifiers when performed on the ipsilateral organ or structure unless there is a specific coding rationale to bypass the edit. The existence of the NCCI PTP edit indicates that the 2 codes generally cannot be reported together unless the 2 corresponding procedures are performed at 2 separate patient encounters or 2 separate anatomic locations. However, if the 2 corresponding procedures are performed at the same patient encounter and in contiguous structures in the same organ or anatomic region, NCCI PTP-associated modifiers generally should not be used. Modifier 59 may be used only if no other appropriate modifier describes the service. For your convenience, you may use this hyperlink below to access more information regarding Modifier 59, CMS MLN SE1418. The article provides more information on the appropriate use of the 59 modifier and can be found in the downloads section at the bottom of the NCCI webpage.

B. How do I know which modifier to use to bypass an edit?

General information about NCCI-associated modifiers can be found in the NCCI Policy Manual, Chapter 1, Section E, available on the CMS NCCI webpage.

C. Can these modifiers that are associated with the NCCI PTP edits be used with all the Column 1 / Column 2 correct coding edits?

No, there are some Column 1 / Column 2 correct coding edits which the CMS does not think would ever warrant the use of any of the modifiers associated with the NCCI PTP edits. These code pairs are assigned a correct coding modifier indicator (CCMI) of "0."

D. If I have a situation where I think a modifier associated with the NCCI program should be used, is there someone who can tell me if I am using the modifier properly?

For more information on the use of modifiers please see the CMS Claims Processing Manual (PDF), Publication 100-04, Chapter 12 and the NCCI Policy Manual for Medicare Services, Chapter 1, Section E, available on the CMS NCCI webpage.

Specific billing and reporting questions should be directed to your local MAC in writing.

E. How should modifier 25 be reported under the NCCI?

Modifier 25 may be appended to an Evaluation & Management (E&M) code when reported with another procedure or other service, on the same day of service to indicate a "significant and separately identifiable" E&M service when appropriate. For additional information, please see the NCCI Policy Manual, Chapter 1, Section E. available on the CMS NCCI webpage.

Please refer to The Medicare Claims Processing Manual (PDF), Publication 100-04, Chapter 12, Section 30.6.6, regarding the use of CPT modifier 25, available on the CMS NCCI webpage.

F. How should modifiers 59 or –X{EPSU} be reported under the NCCI program?

For your convenience, you may use this hyperlink below to access more information regarding Modifiers 59 or –X{EPSU}: CMS MLN SE1418. The article provides more information on the appropriate use of the 59 or –X{EPSU} modifier and can be found in the downloads section at the bottom of the NCCI webpage.

G. How should modifier 91 be reported under the NCCI program?

These edits allow use of NCCI PTP-associated modifier 91 to bypass them if one or more of the individual laboratory tests are repeated on the same date of service. The repeat testing must be medically reasonable and necessary. Modifier 91 may be used to report this repeat testing. 

Based on the "Internet-only Manuals (IOM)," "Medicare Claims Processing Manual," Publication 100-04, Chapter 16, Section 100.5.1, the repeat testing cannot be performed to “confirm initial results; due to testing problems with specimens and equipment or for any other reason when a normal, one-time, reportable result is all that is required.”

Published PTP and MUE Files

A. How do I know what changed in the NCCI PTP and MUE files from quarter to quarter?

The CMS posts the current and previous quarter’s PTP edit and MUE files, and change report files. The change report files are available free to the public and may be found on the CMS Quarterly PTP and MUE Version Update Changes webpage.

B. Why does it sometimes appear that CMS adds edits to the NCCI program in one version, and then in the next version changes or deletes those edits?

The CMS developed the NCCI program to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Part B claims. The coding policies are based on coding conventions defined in the American Medical Association's (AMA’s) CPT Manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, or current coding practice. The NCCI program is responsible for developing, revising, and maintaining NCCI edits, responding to inquiries regarding the NCCI program, and promoting program integrity and compliance. Changes in the NCCI program are the result of comments submitted to the CMS. Prior to implementing new edits, the CMS generally provides a review and comment period to representative national organizations that may be impacted by the edits.  However, there are situations when the CMS thinks that it is prudent to implement edits prior to completion of the review and comment period.  The CMS Central Office evaluates the input from all sources and decides which edits are modified, deleted, or added each quarter.

C. There are some software coding programs that already contain the NCCI PTP edits and published MUEs.  Do I still need to obtain the edits from the CMS website?

At this time, the official method for Medicare providers / suppliers to receive the NCCI PTP edits and published MUEs is through the CMS NCCI webpage. It is the responsibility of the entity billing Medicare to ensure that they bill correctly. Other government and private insurers may choose to adopt Medicare's NCCI methodologies.
The application of Medicare’s NCCI methodologies and thereby the application of Medicare payment policies and rules to claims other than Medicare Part B claims may result in denials by other plans. Plans that voluntarily choose to adopt Medicare's NCCI methodologies should review their edits and consider deactivating individual edits that conflict with their own benefit and coverage determinations.
If you have questions or concerns regarding this process, please contact your payer directly.

D. How often are the NCCI PTP edits and MUEs updated?

The NCCI PTP edits and MUEs are usually updated at least quarterly.

E. If I receive a bundling message that says something is included in a service billed on the same day, and I do not find evidence of this edit in the latest version update of the NCCI program, who should I ask about this denial?

Contact your local A/B MAC about other edits that may be in place on a national or local level which are not NCCI edits.

 

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.