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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 our Commercial and Medicare Advantage claim
payment policies on NCCI edits, which are available 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:
- Commercial: #00.01.56a: National Correct Coding Initiative (NCCI)
Code Pair Edits;
- Medicare Advantage: #MA00.041: National Correct Coding Initiative
(NCCI) Code Pair Edits.
The CMS NCCI tables (Column 1/Column 2) are composed of code pair edits. These
code pair edits identify services that are 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
Independence regardless of the presence of a modifier.
Modifier 25 and modifiers ?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 individual.
Appropriate use of modifiers
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
Update, 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
PTP Coding Edits file for procedure code pair edits and the associated
modifier indicators. ]