CCI edits are pairs of CPT or HCPCS codes not payable separately for a individual patient billed by a provider on a single same day of service without a justifiable overriding causation.
The National Correct Coding Initiative (NCCI) was implemented in 1996. Bundling CCI Edits are among the top reason claims are denied for new providers. Errors can be avoided by following the National Correct Coding Initiative (NCCI) guidelines.
Correct Coding Initiative (CCI) edits are pairs of Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Level II codes that are not separately payable except under certain circumstances. The edits are applied to services billed by the same provider for the same beneficiary on the same date of service. The purpose of the National Correct Coding Manual is to promote correct coding nationwide and to assist physicians in coding services correctly for reimbursement. The policies included in the manual are based on coding conventions as defined by the American Medical Association (AMA) CPT manual.
The relationship is not true for many CCI edits although the Column 2 code is often a component of a more comprehensive Column 1 code. In the latter type of edit, the code pair edit simply represents two codes that should not be reported together, unless an appropriate modifier is used.
Many procedure codes should not be reported together because they are mutually exclusive of each other. Mutually exclusive procedure cannot reasonably be performed at the same anatomic site or beneficiary encounter.
Modifiers may be appended to HCPCS/CPT codes. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI edit if the clinical circumstances do not justify its use. In the modifier indicator column, the indicator 0, 1, or 9 shows whether an NCCI associated modifier allows the code pair to bypass the edit.
The 0 means no modifiers are allowed, the 1 means modifiers may be used when appropriate, the 9 means the edit was deleted retroactively.
The following anatomical modifiers are allowed are E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9.
The following global surgery modifiers are allowed are 25, 58, 78, and 79.
Other modifiers that are allowed are XE, XP, XS, XU, 59, and 91.
Modifier “25” should be appended to an evaluation and management (E/M) code when reported with another procedure on the same day of service. Appending modifier -25 to the E/M code indicates the physician performed a significant, separately identifiable E/M service above and beyond the other service provided.
Modifier 59 is used to indicate a distinct procedural service. To appropriately report this modifier, append modifier -59 to the column 2 code to indicate that the procedure or service was independent from other services performed on the same day. The addition of this modifier represents a distinct procedure or service from others billed on the same date of service. In other words, this may represent a different session, different anatomical site or organ system, separate incision/excision, different lesion, or different injury or area of injury (in extensive injuries).
When used with a CCI edit, modifier -59 indicates that the procedures are different surgeries when performed at different operative areas or at different patient encounters.
Modifier 91 should be appended to laboratory procedure(s) or service(s) to indicate a repeat test or procedure on the same day. This modifier indicates that the physician had to perform a repeat clinical diagnostic laboratory test that was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain medically necessary subsequent reportable test values. This modifier should not be used to report repeat laboratory testing due to laboratory errors, quality control, or confirmation of results.
The CMS website contains a listing of the CCI edits, by specific CPT sections, and is available free for downloading to the public. The CCI Edits manual is also available on the CMS website. These edits are updated quarterly by Correct Coding Solutions LLC. It is important to review these updates quarterly to review if the services/procedures you provide are updated with new edits.