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This is a reminder that as of January 1, 2015, the Centers for Medicare
& Medicaid Services (CMS) National Correct Coding Initiative (NCCI) edits
are applicable to claims submitted on the CMS-1500 claim form or through the
837P transaction. Please refer to the following claim payment policies on NCCI
edits:
- Commercial: #00.01.56a: National Correct Coding Initiative (NCCI)
Code Pair Edits;
- Medicare Advantage: #MA00.041: National Correct Coding Initiative
(NCCI) Code Pair Edits.
Access these policies on our
Medical Policy Portal. Select
Accept and Go to Medical
Policy Online, and then select the
Commercial or
Medicare
Advantage tab from the top of the page, depending on the version of the
policy you'd like to view.
The CMS NCCI tables (Column 1/Column 2) are composed of code pair edits.
These code pair edits identify services that are either a component of a more
comprehensive code or two codes that should not be reported together. Procedure
code pairs designated by CMS with an NCCI modifier indicator of 0 (zero) are
not eligible to be reimbursed separately when reported on the same date of
service for the same member when performed by the same provider. The NCCI edit
identified in the CMS NCCI file for these procedure code pairs will be applied
by AmeriHealth regardless of the presence of a modifier.
Modifiers 25 and ?X{EPSU} and 59
Procedure code pairs designated by CMS with an NCCI modifier indicator of 1,
when clinically appropriate, are eligible to be reported with an appropriate
modifier for separate reimbursement. The most frequently used modifiers are 25
and ?X{EPSU} and 59.
- Modifier 25: Modifier 25 is required when a significant, separately
identifiable Evaluation and Management (E&M) service is performed by the
same physician on the same day of a procedure or other service. For example, if
an E&M service was also performed on the same day as an administration of
an immunization, the E&M service should be billed with the modifier 25.
- Modifiers ?X{EPSU} and 59: Modifiers ?X{EPSU} and 59 are required to
indicate that a procedure or service is separate, distinct, or independent from
other non-E&M services performed on the same day by the same physician.
For more detailed information regarding the appropriate use of these modifiers,
please visit our
Medical Policy Portal. Select
Accept and Go to Medical
Policy Online, and then select the
Commercial or
Medicare
Advantage tab from the top of the page, depending on the version of the
policy you'd like to view:
- Modifier 25:
- –Commercial: #03.00.06l: Modifier 25: Significant,
Separately Identifiable Evaluation and Management Service by the Same Physician
on the Day of a Procedure or Other Service;
- –Medicare Advantage: #MA03.003a: Modifier 25:
Significant, Separately Identifiable Evaluation and Management Service by the
Same Physician on the Day of a Procedure or Other Service.
- Modifiers ?X{EPSU} and 59:
- –Commercial: #03.00.08d: Modifiers XE, XS, XP, XU,
59;
- –Medicare Advantage: #MA03.005a: Modifiers XE, XS, XP,
XU, 59.
Note: As communicated in the July 2015 edition of Partners in Health
UpdateSM, providers should use the more specific ?X{EPSU}
modifiers to accurately represent the circumstances that render non-E&M
services as separate, distinct, or independent. However, modifier 59 can still
be reported if the service cannot be more accurately reported with one of the
four specific modifiers. Providers cannot append more than one of these
modifiers (i.e., XE, XP, XS, XU, or 59) to a single procedure code. Claims
submitted with any of these modifiers may be subject to retrospective review
and audit if it is determined that providers are not using them in accordance
with the billing requirements in our claim payment policies.
Please refer to the
CMS NCCI Edit web page for procedure code pair
edits and the associated modifier indicators.]