This article reviews information regarding what CCI edits are and the information included in those edits, and discusses documentation and CCI edits specific to the Radiology specialty.
The National Correct Coding Initiative (NCCI), also known as CCI, was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. NCCI code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services. In addition to code pair edits, the NCCI includes a set of edits known as Medically Unlikely Edits (MUEs). An MUE is a maximum number of Units of Service (UOS) allowable under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a provider on a date of service for a single beneficiary.
The tables are updated quarterly and loaded into the Centers for Medicare & Medicaid Services’ (CMS) claims payment processing systems and onto the CMS NCCI web pages. The NCCI edits in the Outpatient Code Editor are always one quarter behind the physician edits. The National Correct Coding Initiative Policy Manual for Medicare Services is updated annually in October. To view the code pair edits, MUE tables and NCCI Manual, click here.
Column 1/Column 2 Code Pair Tables
Although the Column 2 code is often a component of a more comprehensive Column 1 code, this relationship is not true for many edits. In the latter type of edit, the code pair edit simply represents two codes that should not be reported together, unless an appropriate modifier is used. For example, a provider should not report a vaginal hysterectomy code and total abdominal hysterectomy code together.
Mutually Exclusive Code (MEC) Code Pair Tables
Many procedure codes should not be reported together because they are mutually exclusive of each other. Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same beneficiary encounter. An example of a mutually exclusive situation is the repair of an organ that can be performed by two different methods. Only one method can be chosen to repair the organ.
A second example is a service that can be reported as an initial service or a subsequent service. With the exception of drug administration services, the initial service and subsequent service cannot be reported at the same beneficiary encounter. In addition, the descriptor of some HCPCS/CPT codes includes a gender-specific restriction on the use of the code. HCPCS/CPT codes specific for one gender should not be reported with HCPCS/CPT codes for the opposite gender.
Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI edit if the clinical circumstances do not justify its use. If the Medicare Program imposes restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI edit if the Medicare restrictions are fulfilled. In the modifier indicator column, the indicator 0, 1 or 9 shows whether an NCCI-associated modifier allows the code pair to bypass the edit. The following Modifier Identifier Table provides a definition of each of these indicators:
Modifier Indicator Table
One of the most difficult documentation challenges are edits seen for radiology services involving multiple procedures performed at the same patient encounter and often transcribed on one report. The use of a modifier may be allowed to indicate both services were performed and meet documentation requirements for separate reporting. If so, use of the modifier indicates:
- Each service is clinically indicated.
- Each service is distinct and separate.
If the documentation doesn’t support both of the criteria above, only the most comprehensive (Column 1) service may be reported.
Documentation TIP: Provide separate documentation for each exam performed. At a minimum, a paragraph (for each exam) should provide the detail required for reporting the service including:
- Clinical indication or reason for the exam
- Technique for the exam
- Findings/impression for the exam
Ultrasound and Duplex Scans
CCI Manual: “Abdominal ultrasound examinations (CPT codes 76700-76775) and abdominal duplex examinations (CPT codes 93975, 93976) are generally performed for different clinical scenarios although there are some instances where both types of procedures are medically reasonable and necessary. In the latter case, the abdominal ultrasound procedure CPT code should be reported with an NCCI-associated modifier.”
This is one example of exams that are “bundled,” or CCI Column 1/Column 2 Code Pair I edits; however, there are many ultrasound exams that are considered an edit when performed with a duplex scan, or at the same patient encounter.
Documentation TIP: If an ultrasound is ordered/performed and the findings require the duplex scan for further evaluation, provide the documentation for each exam in the report. From a CPT reporting perspective, “Doppler” alone doesn’t mean a “duplex” was performed.
Per CPT, “Duplex scan describes an ultrasonic procedure for characterizing the pattern and direction of blood flow in arteries or veins with the production of real-time images integrating B-mode two-dimensional vascular structure, Doppler spectral analysis and color flow Doppler imaging.” Including details/techniques for each exam will prevent a “send-back” or returns for additional information.
CT and CTA
CCI Manual: “Computed tomography (CT) and computed tomographic angiography (CTA) procedures for the same anatomic location may be reported together in limited circumstances. If a single technical study is performed which is utilized to generate images for separate CT and CTA reports, only one procedure, either the CT or CTA, for the anatomic region may be reported. Both a CT and CTA may be reported for the same anatomic region if they are performed at separate patient encounters or if two separate and distinct technical studies, one for the CT and one for the CTA, are performed at the same patient encounter. The medical necessity for the latter situation is uncommon.”
MRI and MRA
CCI Manual: “Similarly magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) procedures for the same anatomic location may be reported together in limited circumstances. If a single technical study is performed which is utilized to generate images for separate MRI and MRA reports, only one procedure, either the MRI or MRA, for the anatomic region may be reported. Both an MRI and MRA may be reported for the same anatomic region if they are performed at separate patient encounters or if two separate and distinct technical studies, one for the MRI and one for the MRA, are performed at the same patient encounter. The medical necessity for the latter situation is uncommon.”
Documentation TIP: Unique, separate data acquisition must be obtained for each service. If a single technical study is used for both exams (i.e., same axial imaging for the MRI and MRA), only the most comprehensive service may be reported. Provide documentation of the technique used for each service; if this is not provided, only the most comprehensive service may be reported.
Angiography/Venography Performed at the Time of Interventional Procedures
CCI Manual: “Diagnostic angiography (arteriogram/venogram) performed on the same date of service bythe same provider as a percutaneous intravascular interventional procedure should be reported with modifier 59. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59. If it is medically reasonable and necessary to repeat only a portion of the diagnostic angiogram, append modifier 52 to the angiogram CPT code. If the prior diagnostic angiogram (fluoroscopic or computed tomographic) was complete, the provider should not report a second angiogram for the dye injections necessary to perform the percutaneous intravascular interventional procedure.”
To ensure appropriate reporting of services provided, differentiation of the work involved in a separate diagnostic RS&I (radiologic supervision and interpretation) and a therapeutic RS&I must be included in the dictated report. The transition from the diagnostic service to the therapeutic service should be apparent (i.e., a statement such as “Based upon the diagnostic findings, I elected to proceed with….”). A diagnostic service defines the condition and determines the need to proceed with the therapeutic intervention. Confirmatory (a previously diagnosed, or known condition), guiding or planning images, or imaging that is required to complete the interventional procedure are included in the therapeutic service RS&I.
Documentation TIP: Document whether or not the patient has had prior diagnostic angiographic studies (e.g., fluoroscopic, CTA, MRA, etc.). If a separate diagnostic angiogram is performed, include the information in the report to support billing the angiogram performed at the same time as the intervention. Dictate separate reports or, if one combined report, include a separate section in the report detailing the diagnostic service (including the technique, imaging, findings and impression). Per CPT instructional notes, the following are examples of what is generally considered a diagnostic angiography and when it
is separately reportable:
- “No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, OR
- A prior study is available, but as documented in the medical record:
- The patient’s condition with respect to the clinical indication has changed since the prior study, OR
- There is inadequate visualization of the anatomy and/or pathology, OR
- There is a clinical change during the procedure that requires new evaluation outside the target area of intervention.”
Medically Unlikely Edits
An MUE for a HCPCS/CPT code is the maximum number of UOS under most circumstances allowable by the same provider for the same beneficiary on the same date of service.
Many factors are considered in determining the MUE value for each HCPCS/CPT. Chapter I of the NCCI Manual includes detailed information. A UOS denial based on the MUE may be appealed. A denial of services due to an MUE is a coding denial, not a medical necessity denial.
A provider/supplier may not issue an Advanced Beneficiary Notice of Noncoverage, or ABN, in connection with services denied due to an MUE and cannot bill the beneficiary for UOS denied based on an MUE.A provider, supplier, healthcare organization or other interested party may request reconsideration of an MUE value for a HCPCS/CPT code. A written request proposing an alternative MUE with rationale may be sent to the address listed below.
Correspondence to CMS about NCCI and its Contents
If the user of the NCCI Manual has concerns regarding the content of the edits, an inquiry may be submitted in writing to:
National Correct Coding Initiative
Correct Coding Solutions LLC
P.O. Box 907
Carmel, IN 46082-0907
Fax number: (317) 571-1745