2021 Updates

APTA’s advocacy efforts to address problematic National Correct Coding Initiative Procedure-to-Procedure edits have had an impact. In response to APTA’s requests for changes to edits that effect the delivery of appropriate physical therapy care CMS has deleted a number of edits that impact common physical therapy code pairs. The deletion of these edits is retroactive to Jan. 1, 2020. For questions about reprocessing of denied claims please contact your Medicare Administrative Contractor or state Medicaid agency. These changes are implemented in the Jan. 1, 2021, update. A table with a list of the common physical therapy code pairs with PTP edits is at the bottom of this page.

(Note: It is important to check each commercial payer’s policy to determine if a payer adopts these changes and/or will allow reprocessing of denied claims.)

Types of Edits

NCCI includes three types of edits: NCCI procedure-to-procedure (PTP) edits, medically unlikely edits (MUEs), and add-on code edits. PTP edits and MUEs are contained in a single table that includes the PTP code pairs that should not be reported together for a number of reasons, as explained in the NCCI coding policy manual.

• NCCI PTP edit prevent inappropriate payment of services that should not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code, called a "pair." If a provider reports the 2 codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI-associated modifier is permitted and reported. The NCCI PTP edits are divided into two provider types:
  PTP edits - Practitioner are applied to claims submitted by physical therapists in private practice, as well as by other nonphysician practitioners and physicians, and by ambulatory surgery centers.
  PTP edits - Hospital are applied to claims submitted for services that are paid under the outpatient prospective payment system; for example, outpatient hospital services, Part B skilled nursing facilities, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers, and certain claims for home health agencies billing under types of  claims identified as 22X, 23X, 75X, 74X, and 34X.
• Medically Unlikely Edits (MUEs) prevent improper payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service under most circumstances able to be reported by the same provider for the same beneficiary on the same date of service. MUEs are divided into three provider types:
  Practitioner MUEs are applied to all claims submitted by physical therapists, physicians, and other practitioners.
  DME Supplier MUEs are applied to claims submitted to DME MACs.
  Facility Outpatient MUEs are applied to all claims for types of bills identified as 13X, 14X, and 85X (critical-access hospitals).
• Add-on code edits consist of a listing of HCPCS and CPT add-on codes with their respective primary codes. An add-on code is eligible for payment only if one of its primary codes is also eligible for payment.

The CPT codes are suffixed with superscript numbers representing the CCI modifier indicator. The modifier indicators are represented by (0), (1), and (9) and are shown after the code number on the NCCI edits tables. Here is what the numbers represent:

• 0 - Indicates that there are no circumstances in which a modifier would be appropriate. The services represented by the code combination will not be paid separately.
• 1 - Indicates that a modifier is allowed in order to differentiate between the services provided. Assuming the modifier is used correctly and appropriately, this specificity provides the basis upon which separate payment for the services billed may be considered justifiable.
• 9 - A "9" indicator is used for all code pairs whose deletion date is the same as their effective date. In other words, these edits are no longer active, so the code combinations are billable, and no modifier is needed.

APTA's Use of 59 or X Modifiers for Code Pairs decision tree can help you determine whether you should use the 59 modifier when submitting a claim for a specific pair of CPT codes on the same day for the same patient. The X modifiers (XE, XS, XP, XU) should be used in place of modifier 59 if one of the X modifiers more specifically describes the reason that both codes be paid. Additional general information concerning NCCI PTP edits and MUEs is found in Chapter I of the NCCI coding policy manual.

Complete List of NCCI Edits

The NCCI coding policy manual, which contains a list of the CCI edits, is available through the CMS website. The chapters generally are organized by CPT coding for medical procedures and services (except for Chapter I, which contains general coding policies, and Chapter XII, which addresses CMS's HCPCS Level II codes under the Part B Carriers' jurisdiction). Each chapter includes mutually exclusive codes as well as the Column One/Column Two code pair edits. The chapter of greatest interest to physical therapists is Chapter XI - Medicine, Evaluation and Management Services, which covers CPT codes 90000-99999.

NCCI is an evolving policy and is subject to change. Codes continue to be modified, added, and deleted. CMS posts quarterly updates to the NCCI PTP edits and MUE edits.

CMS Resources

• How to Use the Medicare NCCI Tools
  This CMS “How To” booklet discusses the Medicare National Correct Coding Initiative (also referred to as NCCI or CCI), which was implemented to promote correct coding methodologies and control improper coding that leads to inappropriate payment. NCCI Procedure-to-Procedure code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.

• NCCI Policy Manual Archive
  These archives contain past versions of the National Correct Coding Initiative Policy Manual.  

• Proper Use of Modifiers 59 & X(EPSU)
  This CMS MLN Matters Article is a resource for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors and Durable Medical Equipment MACs for services provided to Medicare beneficiaries. The article discusses how providers may continue to use the -59 modifier after January 1, 2015, in any instance in which it was correctly used prior to January 1, 2015.

• CMS MLN Matters: Continued Use of Modifier 59 After January 1, 2015
  This CMS MLN Matters Article is a resource for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors and Durable Medical Equipment MACs for services provided to Medicare beneficiaries. The article discusses how providers may continue to use the -59 modifier after January 1, 2015, in any instance in which it was correctly used prior to January 1, 2015.

• CMS MLN Matters: Specific Modifiers for Distinct Procedural
  Services
  This CMS Special Edition MLN Matters Article was published to make certain that institutional therapy providers are aware that CCI edits are applied to all therapy providers. CCI edits are applied to services billed by the same provider for the same beneficiary on the same date of service.

Questions?

CMS instructs those with inquiries about the NCCI program, other than those related to the three types of NCCI edits (PTP, MUE and Add-On), to contact them at NCCIPTPMUE@cms.hhs.gov.

Common Physical Therapy Code Pairs With PTP Edits

(As of January 2021)

These are the most common code pairs used in physical therapy, not a complete list — for the full list of code pairs, see the CMS website.

How to use this table: When pairing any code in Column One with any code in Column Two, if the Modifier Indicator is “1,” apply the 59 modifier or an X modifier to bill both codes when your documentation supports the services as separate and distinct. (See our “Use of 59 or X Modifiers for Code Pairs” reference for guidance.) If the Modifier Indicator is "0", you cannot bill these codes together.