Health Information Management

Q&A: Bypassing NCCI edits

APCs Insider, December 21, 2012

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Q:  We are applying modifiers to line items on claims to bypass the National Correct Coding Initiative (NCCI) edits, but they are not working as we expected.  We’ve stayed away from modifier -59 (distinct procedural service) on purpose, but that doesn’t seem to be working.  Do you know why we can’t override the edit?

A:  We’ll assume that the documentation supports the application of the modifiers to bypass the edits. Some code pairs can never be reported together so regardless of which modifier you report, you can’t bypass the edit.  Each edit pair has a modifier indicator in the NCCI edit file.  This indicators are:
  • 0 – no NCCI-associated modifier can be used with this code pair as there are no circumstances where both procedures should be paid on the same date of service.
  • 1 – NCCI modifier may be reported when appropriate.
  • 9 – NCCI edit does not apply to this code pair – the edit has been deleted retroactively.
Review the code pairs for which the denials are occurring. They may have a modifier indicator of zero (0) and no modifier is ever going to allow payment of the component/column 2 code.  Review the documentation to ensure that all modifiers are supported when it comes to NCCI edit pairs.  The fact that an edit is being triggered should cause you to further review the documentation to ensure that both codes should be reported together.
Many modifiers can be used for NCCI edits, including:
  • Anatomical modifiers (-LT, -RT)
  • Finger and toe modifiers (e.g, -E 1, -F4)
  • Coronary artery modifiers (-LC, -LD, -RC)
  • Level I modifiers (e.g., -25, -27, -59)
 Modifier -59 should be the modifier of last resort and used only if there is no other modifier that would provide specificity to the code pair.
Effective January 1, 2013, CMS has issued some new modifiers to use with NCCI edits which are reportable under the OPPS.  These modifiers are:
  • LM – left main coronary artery
  • RI – ramus intermedius coronary artery
These two modifiers should be added to the list of acceptable modifiers and utilized as appropriate before modifier -59.
For more information, review Transmittal 1136 and the NCCI section of the CMS website.
Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

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