NCCI Edits and Version 26.2

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) edits to combat improper coding that would then lead to inappropriate payment in Medicare Part B claims. CMS owns the NCCI program and is responsible for all decisions regarding its contents. Capital Bridge, LLC is CMS’ contractor for the NCCI. In this article, I will answer some of the more common questions I receive concerning NCCI edits.

In addition, I will be presenting a webinar on June 24, 2020 titled “Understanding NCCI Edits & Modifier 59: Version 26.2“. This webinar will provide participants with information on NCCI Edits Version 26.2 that become effective on July 1, 2020. In addition, I will teach participants changes that occurred in April 2020 that went retroactive to either December 31, 2019 or January 1, 2020. Plus, all participants will receive Gawenda Seminars & Consulting NCCI Edit Version 26.2 “Cheat Sheet” for use of modifier 59 in outpatient therapy. For more details and to register, click HERE.

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How often are the NCCI edits updated?

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When does NCCI Version 26.2 become effective and when will it end?

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I know at the start of Calendar Year 2020, CMS would not pay for a physical therapy evaluation (CPT codes 97161-97163) or an occupational therapy evaluation (CPT code 97165-97167) on the same day therapeutic activities (CPT code 97530) was billed? Is that still the case or did it change?

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I know at the start of Calendar Year 2020, CMS would not pay for a physical therapy evaluation (CPT codes 97161-97163) or an occupational therapy evaluation (CPT code 97165-97167) on the same day group therapy (CPT code 97150) was billed? Is that still the case or did it change?

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If I perform manual therapy (CPT code 97140) on a Medicare beneficiary on the same date of service I also bill a physical therapy and/or occupational therapy evaluation, is modifier 59 required to be appended to either of the CPT codes on the claim form?

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Do other insurance carriers use NCCI Edits and if yes, do they typically use the current version of NCCI Edits used by CMS?

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Is there an easy way to determine if an insurance carrier is utilizing the NCCI edits?

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I have insurance carriers tell me they use the current version of CMS’ NCCI edits, but they are not paying me for my physical or occupational therapy evaluation when billed the same day as therapeutic activities. Do you know why?

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When I bill manual therapy and a physical or occupational therapy evaluation on the same day to an insurance carrier, the insurance carrier is not paying me for manual therapy. Do you know why?

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I see in the NCCI edits, there is a Column 1 code and a Column 2 code. What is the difference between the two?

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Does it matter which CPT code I append Modifier 59 to on the claim form?

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What settings do the NCCI edits apply to?

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Do NCCI edits cross disciplines? Can one disciplines billing impact another disciplines billing?

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How do I access the current version of NCCI on the CMS website?

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When I access the NCCI edits on the CMS website, how do I know if the CPT code in Column 2 is payable on the same date of service that I bill the CPT code in Column 1?

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How do I access Gawenda Seminars & Consulting (GSC) NCCI Edit “cheat sheet” that is specific to outpatient therapy services?

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When I access Gawenda Seminars & Consulting (GSC) NCCI edit “cheat sheet” for outpatient therapy services, how do I know if the CPT code in Column 2 is payable on the same date of service that I bill the CPT code in Column 1?

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How come when I find a CPT code (Code A) in Column 1 and go over to Column 2, I do not see the other CPT code (Code B) listed that I am billing but then when I find Code B in Column 1 and go over to Column 2, I see Code A listed?

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If a provider has concerns about specific NCCI edits, he/she may submit comments in writing to:

National Correct Coding Initiative
Capitol Bridge, LLC
P.O. Box 907
Carmel, IN 46082-0907
Fax #: 317-571-1745

I hope you found this article helpful. If you have additional questions regarding NCCI edits and the use of modifier 59, please write out your question in the Comment Box below and I may possible add it to this article. Thank you for being a Gold Member!