NCCI Edits and Major Changes

April 21, 2020
Rick Gawenda

National Correct Coding Initiative (NCCI) edits are updated quarterly by the Centers for Medicare and Medicaid Services (CMS) and Capital Bridge, CMS’ NCCI coding contractor. Updates occur on January 1, April 1, July 1, and October 1 of each calendar year. Typically, the January 1 update sees the most additions, deletions and revisions due to new, revised and deleted CPT codes taking effect on January 1 of the calendar year.

Due to the COVID-19 Public Health Emergency as well as CMS’s expansion of telehealth services, CMS updated procedure-to-procedure (PTP) edits and Medically Unlikely Edits (MUEs) for Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, retroactive to January 1, 2020. This announcement was posted on April 8, 2020 on the CMS website.

There have been many significant changes (well over 150) to the PTP edits applicable to physical, occupational and speech therapy services with all of them retroactive to January 1, 2020. Many of the NCCI edits have been deleted, including those that became effective January 1, 2020.

I have updated NCCI Version 26.0 for dates of service January 1, 2020 – March 31, 2020 for both the private practice setting and non-private practice settings. In addition, NCCI Version 26.1 for dates of service April 1, 2020 – June 30, 2020 has been published on my website for my Gold Members. To access the NCCI edit reference sheet, click HERE.

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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

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  1. Rick – Thank you for yet again providing timely, concise, and accurate information! Excellent value added to the rehab community!

  2. Rick, I see at the bottom of your cheat sheets it says changes will be in red or blue but I don’t see either of those colors on the cheat sheet itself. Am I missing something?

    1. Because there were over 150 deletions, I did not keep them on this version and put them in blue. I just deleted the CPT codes from Column 2 for both Versions 26.0 and 26.1

  3. I noticed that in both the revised NCCI Version 26.0 and 26.1, there are many boxes that are now blank in column 2 that used to have many codes listed (i.e. Column 1 – 92507, 92523, 97110, 97112, 97116). Could you explain what should be inferred from the blank boxes in Column 2?
    thank you

  4. Great news. Thank you for posting. Do you think these changes will remain in place when the public health emergency is over?

    1. You are welcome and thank you for being a Gold Member! Your question is the million dollar question. Lets hope so!

  5. Hello Rick,

    As Patty had indicated above it looks as though the 92507 no longer has the Column 2 codes listed. Would my interpretation that this no longer requires a modifier for billing with say 97530 be accurate then? In addition, you mentioned it was retroactive for January 1st, would that mean that previous denials due to missing modifiers would now be considered allowed under NCCI?

      1. Hi Rick,

        Thank you for your prompt reply thus 92507 and 97530 could be billed without modifiers and are considered allowed under NCCI guidelines?

        1. As you look at the Column 1 CPT code and go over to the right and look at Column 2. If the code you are looking for is not there, it means that code can be billed the same day as the code in Column 1 and hence, no modifier 59 is required. You then must look the other way at the other combination to make sure no modifier 59 is required as well.

  6. Hello Rick,
    We have had several denials from Anthem and Blue Shield for billing 97530 and evaluation codes together. I contacted the APTA and they provided me with a letter to submit when appealing these claims. According to the APTA representative because of the reversal of these NCCI edits that were added in January, all carriers need to return to allowing for the billing of these two codes together.
    However, when we call Blue Shield, they have no idea what we are talking about. Any advice on having these claims processed correctly?
    Thank you for your time!

    1. We have seen payers like Anthem, Aetna and Humana ignore the edits and just deny one of the CPT codes, make you appeal the denial, and still deny the appeal. If this persists, I would recommend you have your patients complain to their employer and also file a complaint with the state Insurance Commissioner.