NCCI Edits Version 23.0 Update

January 16, 2017
Rick Gawenda

The Centers for Medicare and Medicaid Services (CMS) released National Correct Coding Initiative (NCCI) edits Version 23.0 in November 2016 that is effective for dates of service January 1, 2017 – March 31, 2017. As expected, there were significant additions and deletions due to the new physical and occupational therapy evaluation and reevaluation CPT codes that became effective for dates of service on and after January 1, 2017.

The NCCI edits are not only used by the Medicare program for outpatient therapy services, but are also used by state Medicaid programs as well as some private insurance carriers and workers compensation carriers. Providers who are not aware of the NCCI edits may not have all of their CPT codes paid for on a particular date of service due to the combination of codes being billed on the claim form. This is true for all outpatient therapy settings, including private practice and physician-owned therapy practices. In this article, I will discuss issues and concerns with NCCI edit Version 23.0 for all outpatient therapy settings, including, hospital outpatient therapy departments, skilled nursing facilities, rehabilitation agencies, home health agencies doing Part B in the home, private practice and physician-owned therapy practices. To access the Gawenda Seminars & Consulting NCCI Edits Therapy “Cheat Sheet”, click HERE.

CMS has acknowledged there are three errors in the CCI edit Version 23.0 used by

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  1. Am I reading the sheet correctly that you can no longer charge a PT and an OT eval on the same day no matter the level of complexity?

  2. Do you have the TDL number?
    I am not having any luck dealing with Noridian here in California

  3. I am getting a CCI edit for OT eval 97165 and orthotic management, 97762. Add the XU modifier will not clear the edit. Any thoughts?

  4. I’m looking at the Edits 4/1/17. How can 97161 be used with 97166, but 97166 can’t be used with 97161? Also 97161 & 97162 can be used with 97167, but 97167 can’t be used with 97161 & 97162? This just isn’t making sense, or am I missing something?

    1. That is because one is a component of the other and not the other way around. They each can’t be a component of the other. If that was the case, both codes would require modifier 59.