Health Information Management

Differentiate between types of coding edits to determine appropriate modifier use

JustCoding News: Outpatient, July 11, 2012

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Coders can run into two types of edits that may require them to append modifier -59 (distinct procedural service) to override: National Correct Coding Initiative (NCCI) edits and medically unlikely edits (MUE).

“In a nutshell, NCCI edits target combinations of codes, while MUEs target quantities,” says Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS, president/CEO and principal consultant for SLG, Inc., in Raleigh, N.C.
 NCCI edits
NCCI edits focus on codes that should not be reported together. All of the NCCI edits are available online, allowing easy reference for coders.
CMS updates the National Correct Coding Policy Manual each January, and Chapter 1 of the manual includes instructions on reporting modifiers to bypass bundling edits. According to CMS, coders can report 35 modifiers, when appropriate, to bypass bundling guidelines, Goodman says. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.
The NCCI edits used to consist of two tables: the Column One/Column Two Correct Coding Edit Table and the Mutually Exclusive Edit Table. As part of the April 2012 quarterly update, CMS combined these two tables to create the Column One/Column Two Correct Coding edit file. The file contains edits: pairs of HCPCS codes that, in general, should not be reported together. Each edit has a Column One and Column Two HCPCS code. When a provider reports both codes of an edit pair, the Column Two code is denied and the Column One code is eligible for payment.
Each NCCI edit also includes a modifier indicator. The modifier indicators are as follows:
  • 0: No modifier allowed under any circumstance; the code pair will not be paid separately
  • 1: Modifier -59 is allowed in order to differentiate between services provided; allows for separate payment when used correctly
  • 9: No modifier needed as the edit is inactive as of the posted date and services may be separately billable
Before appending any modifier, coders need to check the modifier indicator for the codes in question, Goodman says.
Keep in mind that some commercial payers also follow the NCCI edits, says Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, executive vice president for Med Law Advisors, Inc., in Atlanta.
“It’s really a good idea to know which payer is following NCCI edits and which isn’t because the bundling edits within the correct coding initiative don’t always marry to how the CPT® guidelines read,” Garrison says.
Medically unlikely edits
MUEs limit the reportable units of certain CPT or HCPCS codes. They represent the maximum number of units of a given service that a patient should receive on a given date of service. CMS bases MUEs on several factors, including anatomy, code description, the agency’s own policies, and the overall nature of a service, says Goodman.
Because it is concerned about potential fraud and abuse, CMS has published some of the MUEs online, but not all of them, says Goodman. CMS generally does not publish codes with an MUE value of 4 or higher, but it may also not publish edits for some codes with lower MUE values if the agency believes those codes are prone to fraud and abuse, she says.
Remember that not all CPT and HCPCS codes have MUE values. In fact, the majority of codes will not trigger an MUE edit, Goodman adds.


Don’t view MUE edits as utilization guidelines, she notes. In certain situations, the provider may legitimately decide the patient needs additional units of a specific service. 
Some of the MUE limits seem obvious based on the type and nature of the service. One example is CPT code 22523 (percutaneous vertebral augmentation, including cavity creation [fracture reduction and bone biopsy included when performed] using mechanical device, one vertebral body, unilateral or bilateral cannulation [e.g., kyphoplasty]; thoracic). This code has an MUE value of one, and the code itself refers to one vertebral body. “It’s always important to look to the code first for clues, and that might tell you what the [MUE] value will be,” Goodman says.
Overriding edits
In some cases, coders should override the NCCI or MUE edits by appending a modifier. Remember to always append the modifier to the column 2 code in an NCCI pair, Garrison says.
Ask yourself these questions when determining whether modifier -59 is appropriate:
  1. Do the codes bundle together (based on CPT® or CCI guidelines)? If yes, move to question 2. If no, report both codes without unbundling the modifier. To determine whether the codes are subject to bundling or another edit, follow these steps:
  • Check CCI edits (through computer software, the Medicare website, or manuals)
  • If there’s an edit, you must determine how to bypass the edit:
    • Read introduction and section-specific guidelines in CCI to determine the rationale of the edit
    • Based on guidelines, review documentation to determine whether the patient’s specific case falls under the guideline
    • If there’s no CCI edit, is there a CPT guideline preventing coding both together?
    • Understand the separate procedure designation
    • Review CPT Assistant and CPT Manual guidelines
    • Based on guidelines, review documentation to determine whether the guidelines apply to the patient’s specific case
  1. Was the procedure distinct from other procedures (different site, session, patient, diagnosis, etc.)? If yes, move to question 3. If no, only bill the primary service and not the bundled code.
  2. Does the CCI edit have a modifier indicator of 0? If yes, do not use modifier -59 and do not bill separately. If no, move to question 4.
  3. Is there a better (more specific) modifier than modifier -59? If yes, use the other modifier to separately bill. If no, use modifier -59 to separately bill.
Case example
A patient presented to the ED with emesis, fever, and orthostasis. Treatment was initiated with infusion of two antibiotics, administered sequentially over total time of 95 minutes in the right forearm. Hydration occurs concurrently with the administration of the antibiotics. Unusual swelling is noticed in the right arm so infusion of an anti-emetic is begun in the left forearm.
Chapter 11 of the NCCI Policy Manual for Medicare Services states:
1. CPT codes 96360-96379 and C8957 describe hydration and therapeutic or diagnostic injections and infusions of non-chemotherapeutic drugs. CPT codes 96401-96549 describe administration of chemotherapy or other highly complex drug or biologic agents. Issues related to chemotherapy administration are discussed in this section as well as Section N. (Chemotherapy Administration).
2. CPT codes 96360, 96365, 96374, 96409, and 96413 describe “initial” service codes. For a patient encounter only one “initial” service code may be reported unless it is medically reasonable and necessary that the drug or substance administrations occur at separate intravenous access sites. To report two different “initial” service codes use NCCI-associated modifiers.
Based on the information in the documentation and the NCCI guidelines, you should report CPT code 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour ) twice, Goodman says. Report 96365 once without modifier -59 for the first infusion, then report it a second time with modifier -59 for the infusion in the left forearm.
E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at


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