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CMS developed the NCCI to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims.

The Centers for Medicare and Medicaid Services developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims.

CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.

For an explanation of the rationale for NCCI edits and as a general reference, carriers and fiscal intermediaries can use the National Correct Coding Initiative Coding Policy Manual for Medicare Services, which is updated annually.

2020 Update

The 2020 version of the National Correct Coding Initiative Policy Manual for Medicare Services is posted on the National Correct Coding Initiative webpage of the CMS website. Potential changes to CMS' correct coding methodologies that would have been damaging to the physical therapy profession were averted in January after a concerted advocacy effort by APTA and others to convince CMS to reverse its decision.

For the most part, coding rules regarding billing for certain interventions delivered on the same day as evaluations remain as they were in 2019. The one change: CMS will require the -59 modifier/X modifier to be applied in order for a PT to receive payment for furnishing both manual therapy (97140) and an evaluation using any of the physical therapy evaluation codes (97161, 97162, 97163) on the same day for the same patient, or if billing for therapeutic activities (97530) or group therapy (97150) delivered on the same day as a physical therapy reevaluation (97164).

Types of Edits

NCCI includes three types of edits: NCCI procedure-to-procedure (PTP) edits, medically unlikely edits (MUEs), and add-on code edits. PTP edits and MUEs are contained in a single table that includes the PTP code pairs that should not be reported together for a number of reasons, as explained in the NCCI coding policy manual.

NCCI PTP edits prevent inappropriate payment of services that should not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code, called a "pair." If a provider reports the 2 codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI-associated modifier is permitted and reported. The NCCI PTP edits are divided into two provider types:

  • PTP edits. Practitioner are applied to claims submitted by physical therapists in private practice, as well as by other nonphysician practitioners and physicians, and by ambulatory surgery centers.
  • PTP edits. Hospital are applied to claims submitted for services that are paid under the outpatient prospective payment system; for example, outpatient hospital services, Part B skilled nursing    facilities, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers, and certain claims for home health agencies billing under types of claims identified as 22X, 23X, 75X, 74X, and 34X.

Common Therapy Code Pairs with PTP Edits

Column I

Column II

92507 Treatment of Speech Disorder

92508 Treatment of Speech Disorder Group

97110 (1) Therapeutic Exercise

95992 Canalith Repositioning Procedure

97110 (1) Therapeutic Exercise

97112 (1) Neuromuscular Reeducation

97140 (1) Manual Therapy

97530 (1) Therapeutic Activities

97161-97163

97140 (1) Manual Therapy

97164 Physical Therapy Reevaluation

CMS has bundled 97164 with all 97000 series therapy codes. If a provider performs a reevaluation during the same visit as a therapeutic procedure, the provider may bill for both services by appending the -59 modifier/X modifier to the reevaluation code. The reevaluation must be medically necessary and distinctly separate from the therapeutic procedure, and the distinction must be indicated clearly in the documentation.

97032 Electrical Stimulation (manual)

64550 (1) Applications of Surface (transcutaneous) Neurostimulator

97113 Aquatic Therapy

97110 (1) Therapeutic Exercise

97140 Manual Therapy

97018 (1) Paraffin Bath

97530 (1) Therapeutic Activities

97750 (1) Physical Performance Test & Measures

97150 Group Therapy

97110 (1) Therapeutic Exercise

97112 (1) Neuromuscular Reeducation

97113 (1) Aquatic Therapy

97116 (1) Gait Training

97140 (1) Manual Therapy

97530 Therapeutic Activities

97113 (1) Aquatic Therapy

97116 (1) Gait Training

97532 (1) Development of Cognitive Skills

97533 (1) Sensory Integrative Techniques

97535 (1) Self-Care/Home Management

97750 (1) Physical Tests and Measurements

97597, 97598 Removal of Devitalized Tissue

97022 (1) Whirlpool

97755 Assistive Technology Assessment

97530 (1) Therapeutic Activities

97763 (0) Subsequent encounter for orthotic/prosthetic management and training purposes

97760 Orthotic(s) Management and Training, initial encounter

97110 (1) Therapeutic Exercise

97112 (1) Neuromuscular Reeducation

97116 (1) Gait Training

97124 (1) Massage

97140 (1) Manual Therapy

97763 (1) Subsequent encounter for orthotic/prosthetic management and training purposes

97761 Prosthetic Training, initial encounter

97763 (1) Subsequent encounter for orthotic/prosthetic management and training purposes

 

Medically Unlikely Edits (MUEs) prevent improper payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service under most circumstances able to be reported by the same provider for the same beneficiary on the same date of service.MUEs are divided into three provider types:

  • Practitioner MUEsare applied to all claims submitted by physical therapists, physicians, and other practitioners.
  • DME Supplier MUEsare applied to claims submitted to DME MACs.
  • Facility Outpatient MUEsare applied to all claims for types of bills identified as 13X, 14X, and 85X (critical-access hospitals).

Add-on code edits consist of a listing of HCPCS and CPT add-on codes with their respective primary codes. An add-on code is eligible for payment only if one of its primary codes is also eligible for payment.

Superscript Numbers

The CPT codes are suffixed with superscript numbers representing the CCI modifier indicator. The modifier indicators are represented by (0), (1), and (9) and are shown after the code number on the NCCI edits tables. Here is what the numbers represent:

  • 0 - Indicates that there are no circumstances in which a modifier would be appropriate. The services represented by the code combination will not be paid separately.
  • 1 - Indicates that a modifier is allowed in order to differentiate between the services provided. Assuming the modifier is used correctly and appropriately, this specificity provides the basis upon which separate payment for the services billed may be considered justifiable.
  • 9 - A "9" indicator is used for all code pairs whose deletion date is the same as their effective date. In other words, these edits are no longer active, so the code combinations are billable, and no modifier is needed.

APTA's Use of Modifier 59 decision tree can help you determine whether you should use the 59 modifier to claim a specific pair of CPT codes on the same day for the same patient. The X modifiers (XE, XS, XP, XU) should be used in place of modifier 59 if one of the X modifiers more specifically describes the reason that both codes be paid. Additional general information concerning NCCI PTP edits and MUEs is found in Chapter I of the NCCI coding policy manual.

Complete List of NCCI Edits

The NCCI coding policy manual, which contains a list of the CCI edits, is available through the CMS website. The chapters generally are organized by CPT coding for medical procedures and services (except for Chapter I, which contains general coding policies, and Chapter XII, which addresses CMS's HCPCS Level II codes under the Part B Carriers' jurisdiction). Each chapter includes mutually exclusive codes as well as the Column One/Column Two code pair edits. The chapter of greatest interest to physical therapists is Chapter XI - Medicine, Evaluation and Management Services, which covers CPT codes 90000-99999.

NCCI is an evolving policy and is subject to change. Codes continue to be modified, added, and deleted. CMS posts quarterly updates to the NCCI PTP edits and MUE edits.

CMS Resources

Questions

CMS instructs those with inquiries about the NCCI program, other than those related to the three types of NCCI edits (PTP, MUE and Add-On), to contact them at NCCIPTPMUE@cms.hhs.gov.