NCCI Edits Version 23.1 in Effect

April 3, 2017
Rick Gawenda

The Centers for Medicare and Medicaid Services (CMS) has released the quarterly update of the National Correct Coding Initiative (NCCI) edits. NCCI Edit Version 23.1 is in effect for dates of service April 1, 2017 – June 30, 2017. NCCI edits are used by CMS in the outpatient therapy realm in all practice settings including therapist owned private practice, physician owned therapy practices, home health agencies providing Part B therapy in the home, rehabilitation agencies, skilled nursing facilities doing Part B therapy, comprehensive outpatient rehabilitation facilities and hospital outpatient therapy departments.

Regarding hospitals, this would include critical access hospitals and Medicare beneficiaries who may be an inpatient, but does not have any Part A benefits, thus the therapy that was provided is being billed under their Part B benefits. This would also include Medicare beneficiaries who are seen by therapy while in the emergency department or under observation status and do not get admitted to the hospital. The therapy the beneficiary received in these settings are being billed to the Medicare program as outpatient therapy services under their Part B benefits.

Version 23.1 contains several changes regarding the new physical and occupational therapy evaluation and reevaluation CPT codes for both the private practice version and non-private practice version. To access NCCI Edits Version 23.1, 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. Our SNF tried billing our 97162 (PT) & 97166 (OT) with the 59 modifier on the 97166 on the same day & 97166 came back as non covered. Looking at the CCI Edits (4/1/17) it doesn’t show that 97166 is not allowed with 97162. Are we no longer able to do any PT & OT evals on the same day under Part-B and get paid for the services provided? Thanks

    1. Based on the information you have provided, it appears to be an issue with your Medicare Administrative Contractor (MAC) and I would recommend you contact them. I say this based on the assumption that the claim did reach your MAC, your MAC denied 97166 and on the EOB/ERA states its due to a CCI edit issue.

  2. Any idea why the 59 modifier is needed on the OT evaluation when billed on the same day as a PT evaluation? When this originally happened back in January, I read via several list serves that this was an error with the CCI edit table, but it would appear that is not the case? PT and OT evaluations are routinely billed on the same day, and are most certainly separate and distinct. I am interested in the rationale from CMS as to why they added this edit to the table? Any insight? Thank you.

    1. Unfortunately, I can’t speak on behalf of CMS and their rationale for the need for modifier 59 when PT and OT both bill an evaluation on the same day.

  3. I recently started using WebPT and I noticed that they automatically place the 59 modifier before the KX modifier. I was instructed awhile ago that the 59 should be after the KX modifier. Am I wrong about this?

  4. Earlier, we were informed that there was an error re: charging PT and OT evals codes on the same day. And that this would be corrected with the April 2017 CCI edits.
    In reviewing the cci edits that are effective April 2017, cpt codes 97161 paired with 97165,97166, 97167 or 97168 requires a -59 modifier. Is this correct?
    Thank you!

    1. That is correct. In the January 2017 version, it did not allow for the modifier 59 to be appended to the occupational therapy evaluation codes.