NCCI Edit Files & The Data Filter

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Despite numerous educational programs and journal articles related to the National Correct Coding Initiative (NCCI) edits, many wound care stakeholders continue to be misinformed. This time last year, Today’s Wound Clinic provided education about the NCCI Policy Manual and the NCCI procedure-to-procedure (PTP) edits.¹ In July 2018, we provided education about the NCCI PTP edits for evaluation and management (E&M) services/clinic visits performed on the same day as a procedure.² Nevertheless, the No. 1 question that this author continues to receive from wound care professionals and wound care manufacturers is: “Will wound care professionals receive Medicare reimbursement for [a specific wound care procedure/service] performed during the same patient encounter with [another specific wound care procedure/service]?”

For some reason, wound care stakeholders have the mistaken idea that answering that question remains a mystery. The NCCI edit guidelines are clearly described in the NCCI Policy Manual,³ which is updated annually and posted on the Medicare website in October (for the following year). Each October, when the new NCCI Policy Manual is posted on Medicare’s website, this author always reads the introduction and chapters 1, 3, 4, 11, and 12, which pertain to the common wound care-related procedures and services. All wound care stakeholders are encouraged to read the chapters of the NCCI Policy Manual that pertain to the procedures and services necessary for the successful function of their wound management practices. The short, concise chapters of the manual provide guidelines about which procedures/services are considered components of other procedures/services. 

The NCCI PTP edit files state when two procedure Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT^®) codes may not be reported together (except under special circumstances). If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together when the two procedures are performed at different anatomic sites or different patient encounters. Modifier 59 and other NCCI-associated modifiers shall not be used to bypass an NCCI PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.

One of the common misuses of Modifier 59 is related to the portion of its definition that allows its use to describe a “different procedure or surgery.” The code descriptors of the two codes of a code pair edit usually represent different procedures or surgeries. The edit indicates that the two procedures/surgeries cannot be reported together if performed at the same anatomic site and the same patient encounter. The provider cannot use Modifier 59 for such an edit based on the two codes being different procedures/surgeries. However, if the two procedures/surgeries are performed at separate anatomic sites or at separate patient encounters on the same date of service, Modifier 59 may be appended to indicate that they are different procedures/surgeries on that date of service. There is an appropriate use for Modifier 59 that is applicable only to codes for which the unit of service is a measure of time (eg, per 15 minutes, per hour). If two separate and distinct timed services are provided in separate and distinct time blocks, Modifier 59 may be used to identify the services. The separate and distinct time blocks for the two services may be sequential to one another or split. 

Use of Modifier 59 to indicate different procedures/surgeries does not require a different diagnosis for each HCPCS/CPT-coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of Modifier 59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters. From an NCCI perspective, the definition of different anatomic sites includes different organs, different anatomic regions, or different lesions in the same organ. It does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site. While the NCCI Policy Manual is updated annually on Oct. 1, the NCCI PTP edit files⁴ are updated quarterly (Jan. 1,  April 1, July 1, Oct. 1). When the quarterly edits are released, this author uses the data-filter feature of the PTP edit files to learn if Medicare will pay for both wound care procedures/services that are commonly performed together. Because the data filter works almost instantly, this author can complete the entire review in under 30 minutes. 

If wound care stakeholders are unfamiliar with the data filter for the PTP edit files, the Medicare Learning Network^® offers a resource⁵ that clearly describes how to use the NCCI edit tools. Wound care stakeholders should download and read the information. Pages 17-19 of the booklet provide great instructions and screenshots of how the data filter works. By learning how to use the data filter, wound care stakeholders should no longer have to ask others if both procedures/services performed on the same day will receive Medicare payment. See the Table above for quick steps to navigate the NCCI PTP edit files by using the data filter. 

The only way to learn how to use this simple NCCI PTP edit file data filter is to practice searching the files for the answers to the most common NCCI questions. If you have not yet downloaded and read the instructions for using the NCCI PTP edit files, you should do so before proceeding with the practice exercises found above. (Note: The answers to the practice exercises can be found above.)

Once you have completed the NCCI PTP edit practice exercises, if you have questions about the answers, consult the NCCI Policy Manual chapter(s) pertaining to the code pairs in question. Readers may also send questions via email to kathleendschaum@bellsouth.net.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the TWC editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net

References
1. Schaum K. Business briefs: 2018 NCCI policy manual & edits. TWC. 2018;12(2):6-10. 

2. Schaum K. Business briefs: when should you bill for an E&M or clinic visit and a procedure on the same day? TWC. 2018;12(7):6-30.  

3. National correct coding initiative edits. CMS. 2018. Accessed online: www.cms.gov/medicare/coding/nationalcorrectcodinited/index.html

4. PTP coding edits. CMS. 2018. Accessed online: www.cms.gov/medicare/coding/nationalcorrectcodinited/ncci-coding-edits.html

5. How to use the medicare national correct coding initiative (NCCI) tools. Medicare Learning Network. 2018. Accessed online: www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/how-to-use-ncci-tools.pdf