Q. I understand that the Centers for Medicare & Medicaid Services has added National Correct Coding Initiative (NCCI) edits that no longer allow the billing of debridement with hundreds of surgical codes. What is the impact? How do NCCI edits affect us in general?
A. NCCI edits define when two procedure codes may not be reported together except under special circumstances. Medicare implemented NCCI to promote national correct coding methodologies and to control improper coding, which leads to inappropriate payment. Your billers should check the edits whenever two or more procedures are billed for the same patient on the same date of service. If procedures are billed incorrectly and denied, Medicare prohibits you from billing the patient for the denied services, and an Advance Beneficiary Notice of Noncoverage (ABN) cannot be used.

When a claim is processed by Medicare or a Medicare contractor, the system tests every pair of procedures with the NCCI edit rules. The column 2 code of the Column One/Column Two Correct Coding edit file of the NCCI is often a component of a more comprehensive column 1 code. If a pair of billed codes matches a pair of codes listed in the edits, the code listed in column 2 of the Column One/Column Two Correct Coding edit file of the NCCI will be denied. However, an appropriate modifier can bypass the edit, providing the procedures are performed at different anatomic sites, or in the case of repeat clinical diagnostic laboratory tests. Supporting documentation must be in the beneficiary’s medical record.

The NCCI-associated modifiers are as follows:

E2 F1 LD R1 T1 XS 25
E3 F2 LM RT T2 XP 27
E4 F3 LT T3 XU 57
F4 T4 XS 58
F5 T5 59
F6 T6 78
F7 T7 78
F8 T8 91

Table 1 defines modifier indicators and notes whether a modifier allows for the code pair to bypass the edit. Guidance on how to use all NCCI tools can be found at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCITools.pdf.

In October 2016, thousands of new code pairs were added to the list of bundled codes, many of which bundle debridement services into other surgical and medical procedures. [Editor’s note: See “Imaging: X-Rays and Computed Tomography” in the November 2016 issue of JUCM: http://jucm.com/imaging-x-rays-computed-tomography/.] These are the debridement codes added to the edits:

  • 11000 through 11006, debridement of extensive eczematous or infected skin
  • 11042 through 11047, debridement of subcutaneous tissue
  • 11042 through 11047, debridement of subcutaneous tissue
  • 97597 through 97598, debridement without excision
Table 1. Modifiers Indicators
Modifier Indicator Definition
0 (not allowed) There are no modifiers associated with NCCI that are allowed to be used with this PTP code pair; there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider.
1 (allowed) The modifiers associated with NCCI are allowed with this PTP code pair when appropriate.
9 (not applicable) This indicator means that an NCCI edit does not apply to this PTP code pair. The edit for this PTP code pair was deleted retroactively.

For example, Current Procedural Terminology (CPT) codes 10120 (“Incision and removal of foreign body, subcutaneous tissues; simple”) and 10121 (“. . . complicated”) are now bundled with the debridement codes listed before this paragraph. If you were performing debridement in a separate body area from where the removal of the foreign body took place, your biller would have to add modifier -59 to the debridement code in order for it to pass the NCCI edit. If the modifier is not there, the procedure will be denied as being included in the service performed for CPT code 10120 or 10121.

Additional bundled code pairs involving debridement services are the cast application and strapping codes, 29000 through 29584. These also have a modifier indicator of “1” so that an appropriate modifier will bypass the edit when necessary

The Effects of the National Correct Coding Initiative
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