Medicaid NCCI 2021 Coding Policy Manual –
CHAPTER IGENERAL CORRECT CODING POLICIESNATIONAL CORRECT CODING INITIATIVE POLICY MANUALFOR MEDICAID SERVICESRevised January 1, 2021Current Procedural Terminology (CPT) codes, descriptions andother data only are copyright 2020 American Medical Association.All rights reserved.CPT is a registered trademark of the American MedicalAssociation.Applicable FARS\DFARS Restrictions Apply to Government Use.Fee schedules, relative value units, conversion, prospectivepayment systems factors and/or related components are notassigned by the AMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly or indirectlypractice medicine or dispense medical services. The AMA assumesno liability for the data contained or not contained herein.Revision Date (Medicaid): 1/1/2021
Table of ContentsList of Acronyms . I-3Chapter I . I-5General Correct Coding Policies . I-5A.Introduction .I-5B.Coding Based on Standards of Medical/Surgical Practice.I-9C.Medical/Surgical Package .I-12D.Evaluation & Management (E&M) Services .I-17E.Modifiers and Modifier Indicators .I-19F.Standard Preparation/Monitoring Services for Anesthesia.I-25G.Anesthesia Service Included in the Surgical Procedure I-26H.HCPCS/CPT Procedure Code Definition .I-27I.CPT Manual and NCCI Program Instructions .I-28J.“Separate Procedure” Definition .I-28K.Family of Codes .I-29L.More Extensive Procedure .I-29M.Sequential Procedure .I-31N.Laboratory Panel .I-31O.Misuse of Column Two Code with Column One Code .I-31P.Mutually Exclusive Procedures .I-32Q.Gender-Specific Procedures .I-33R.Add-on Codes .I-33S.Reserved for Future Use .I-34T.Unlisted Procedure Codes .I-34U.Reserved for Future Use .I-34V.Medically Unlikely Edits (MUEs) .I-35W.Medicaid Add-On Code (AOC) edits .I-41Revision Date (Medicaid): 1/1/2021I-2
List of VPLCLDLTM.D.MCDMCD NCCIMCRMRAMRIMUENCCIPETPTPRACRCAnesthesia AssistantAmerican Medical AssociationAdd-On CodeAmbulatory Surgical/Surgery CenterComplete Blood CountCode of Federal RegulationsCenters for Medicare & Medicaid ServicesChiropractic Manipulative TreatmentCytomegalovirusCentral Nervous SystemCommercial Off-the-ShelfContinuous positive Airway PressureCardio-Pulmonary ResuscitationCurrent Procedural TerminologyCertified Registered Nurse AnesthetistComputed TomographyComputed Tomographic AngiogramDoctor of OsteopathyDurable Medical EquipmentDepartment of JusticeEvaluation & ManagementElectroencephalographElectromyogramFine Needle AspirationHealthcare Common Procedure Coding SystemHealth Insurance Portability and Accountability Act of1996Human Leukocyte AntigenIntermittent Positive Pressure BreathingIntravenous PyelogramLeft Circumflex Coronary ArteryLeft Anterior Descending Coronary ArteryLeft SideMedical DoctorMedicaidMedicaid National Correct Coding InitiativeMedicareMagnetic Resonance AngiogramMagnetic Resonance ImagingMedically Unlikely EditNational Correct Coding InitiativePositron Emission TomographyProcedure-to-ProcedureRecovery Audit ContractorsRight Coronary ArteryRevision Date (Medicaid): 1/1/2021I-3
RS&IRTSPECTSSAUPICTCUOSVADWBCRadiological Supervision and InterpretationRight SideSingle Photon Emission Computed TomographySocial Security ActUnified Program Integrity ContractorTechnical ComponentUnits of ServiceVentricular Assist DeviceWhite Blood CellRevision Date (Medicaid): 1/1/2021I-4
Chapter IGeneral Correct Coding PoliciesA.IntroductionHealth care providers use Healthcare Common Procedure CodingSystem/Current Procedural Terminology (HCPCS/CPT) codes toreport medical services performed on patients to state Medicaidagencies or fiscal agents. HCPCS consists of Level I CPT codesand Level II codes. CPT codes are defined in the AmericanMedical Association’s (AMA) “CPT Manual,” which is updated andpublished annually. The HCPCS Level II codes are defined by theCenters for Medicare & Medicaid Services (CMS) and are updatedthroughout the year as necessary. Changes in CPT codes areapproved by the AMA CPT Editorial Panel, which meets 3 times peryear.The CPT and HCPCS Level II codes define medical and surgicalprocedures performed on patients. Some procedure codes are veryspecific defining a single service (e.g., CPT code 93000(electrocardiogram)) while other codes define proceduresconsisting of many services (e.g., CPT code 58263 (vaginalhysterectomy with removal of tube(s) and ovary(s) and repair ofenterocele)). Because many procedures can be performed bydifferent approaches, different methods, or in combination withother procedures, there are often multiple HCPCS/CPT codesdefining similar or related procedures.The CPT and HCPCS Level II code descriptors usually do notdefine all services included in a procedure. There are oftenservices inherent in a procedure or group of procedures. Forexample, anesthesia services include certain preparation andmonitoring services.The CMS established the National Correct Coding Initiative(NCCI) program to ensure the correct coding of services. TheNCCI program includes 2 types of edits: National Correct CodingInitiative (NCCI) Procedure-to-Procedure (PTP) edits andMedically Unlikely Edits (MUEs).NCCI PTP edits prevent inappropriate payment of services thatgenerally should not be reported together. Each edit has aColumn One and Column Two HCPCS/CPT code. If a provider reportsthe 2 codes of an edit pair for the same beneficiary on the samedate of service, the Column Two code is denied and the ColumnOne code is eligible for payment. However, if it is clinicallyappropriate to use an NCCI PTP-associated modifier, both theRevision Date (Medicaid): 1/1/2021I-5
Column One and Column Two codes are eligible for payment. (NCCIPTP-associated modifiers and their appropriate use are discussedin Section E of this chapter.)For some NCCI PTP edits, the Column Two code is a component of amore comprehensive Column One code (e.g., an exploratorylaparotomy is not a separately reportable service when anabdominal hysterectomy is performed). However, thecomprehensive/component relationship is not true for many edits.For some edits, the code pair simply represents 2 codes thatshould not be reported together. For example, a provider shallnot report a vaginal hysterectomy code and total abdominalhysterectomy code together because those procedures areconsidered to be mutually exclusive.In this chapter, sections B – R address various issues relatingto NCCI PTP edits.MUEs prevent payment for a potentially inappropriatenumber/quantity of the same service on a single day. An MUE fora HCPCS/CPT code is the maximum number of units of service (UOS)under most circumstances reportable by the same provider for thesame beneficiary on the same date of service. The ideal MUEvalue for a HCPCS/CPT code is one that allows the vast majorityof appropriately coded claims to pass the MUE. For moreinformation concerning MUEs, see Section V of this chapter.The presence of a HCPCS/CPT code in an NCCI PTP edit, or of anMUE value for a HCPCS/CPT code does not necessarily indicatethat the code is covered by any state Medicaid program or by allstate Medicaid programs.Claim lines that are denied due to an NCCI PTP edit or MUE maybe resubmitted pursuant to the instructions established by eachstate Medicaid agency.HCPCS/CPT codes that are denied based on NCCI PTP edits or MUEsmay not be billed to Medicaid beneficiaries.For information concerning the process for requestingreconsideration of NCCI PTP edits or MUEs, please refer to theIntroduction Chapter of this Manual in the section titledCorrespondence with the CMS about the Medicaid NCCI program andits Contents.In this Manual, many policies are described using the term“physician.” Unless indicated differently, the use of this termRevision Date (Medicaid): 1/1/2021I-6
does not restrict the policies to physicians only but applies toall practitioners (including dentists), hospitals, or providerseligible to bill the relevant HCPCS/CPT codes pursuant toMedicaid program rules in each state. In some sections of thisManual, the term “physician” would not include some of theseentities because specific rules do not apply to them.Physicians must report services correctly. This is true even inthe absence of specific edits in the Medicaid NCCI program ortheir implementation in individual states. There are certaintypes of improper coding that physicians must avoid.Procedures shall be reported with the most comprehensive CPTcode that describes the services performed. Physicians must notunbundle the services described by a HCPCS/CPT code. Someexamples follow: A physician shall not report multiple HCPCS/CPT codes whena single comprehensive HCPCS/CPT code describes theseservices. For example, if a physician performs a vaginalhysterectomy on a uterus weighing less than 250 grams withbilateral salpingo-oophorectomy, the physician shall reportCPT code 58262 (Vaginal hysterectomy, for uterus 250 g orless; with removal of tube(s), and/or ovary(s)). Thephysician shall not report CPT code 58260 (Vaginalhysterectomy, for uterus 250 g or less) plus CPT code 58720(Salpingo-oophorectomy, complete or partial, unilateral orbilateral (separate procedure)). A physician shall not fragment a procedure into componentparts. For example, if a physician performs an analendoscopy with biopsy, the physician shall report CPT code46606 (Anoscopy; with biopsy, single or multiple). It isimproper to unbundle this procedure and report CPT code46600 (Anoscopy; diagnostic,.) plus CPT code 45100(Biopsy of anorectal wall, anal approach.). The lattercode is not intended to be used with an endoscopicprocedure code. A physician shall not unbundle a bilateral procedure codeinto 2 unilateral procedure codes. For example, if aphysician performs bilateral mammography, the physicianshall report CPT code 77066 (Diagnostic mammography bilateral). The physician shall not report CPT code 77065(Diagnostic mammography. unilateral) with 2 UOS or77065LT plus 77065RT.Revision Date (Medicaid): 1/1/2021I-7
A physician shall not unbundle services that are integralto a more comprehensive procedure. For example, surgicalaccess is integral to a surgical procedure. A physicianshall not report CPT code 49000 (Exploratorylaparotomy,.) when performing an open abdominal proceduresuch as a total abdominal colectomy (e.g., CPT code 44150).Physicians must avoid downcoding. If a HCPCS/CPT code existsthat describes the services performed, the physician must reportthis code rather than report a less comprehensive code withother codes describing the services not included in the lesscomprehensive code. For example, if a physician performs aunilateral partial mastectomy with axillary lymphadenectomy, theprovider shall report CPT code 19302 (Mastectomy, partial.;with axillary lymphadenectomy). A physician shall not reportCPT code 19301 (Mastectomy, partial.) plus CPT code 38745(Axillary lymphadenectomy; complete).Physicians must avoid upcoding. A HCPCS/CPT code may bereported only if all services described by that code have beenperformed. For example, if a physician performs a superficialaxillary lymphadenectomy (CPT code 38740), the physician shallnot report CPT code 38745 (Axillary lymphadenectomy; complete).Physicians must report UOS correctly. Each HCPCS/CPT code has adefined unit of service for reporting purposes. A physicianshall not report UOS for a HCPCS/CPT code using a criterion thatdiffers from the code’s defined unit of service. For example,some therapy codes are reported in fifteen-minute increments(e.g., CPT codes 97110-97124). Others are reported per session.A physician shall not report a “per session” code using fifteenminute increments.The MUE values and NCCI PTP edits are based on services providedby the same physician to the same beneficiary on the same dateof service. Physicians shall not inconvenience beneficiaries norincrease risks to beneficiaries by performing services ondifferent dates of service to avoid MUE or NCCI PTP edits.In 2010 the “CPT Manual” modified the numbering of codes so thatthe sequence of codes as they appear in the “CPT Manual” doesnot necessarily correspond to a sequential numbering of codes.In the “National Correct Coding Initiative Policy Manual forMedicaid Services,” use of a numerical range of codes reflectsall codes that numerically fall within the range regardless oftheir sequential order in the “CPT Manual.”Revision Date (Medicaid): 1/1/2021I-8
This chapter addresses general coding principles, issues, andpolicies. Many of these principles, issues, and policies areaddressed further in subsequent chapters dealing with specificgroups of HCPCS/CPT codes. In this chapter, examples are oftenused to clarify principles, issues, or policies. The examplesdo not represent the only codes to which the principles, issues,or policies apply.B.Coding Based on Standards of Medical/Surgical PracticeMost HCPCS/CPT code defined procedures include services that areintegral to them. Some of these integral services have specificCPT codes for reporting the service when not performed as anintegral part of another procedure. (For example, CPT code36000 (introduction of needle or intracatheter into a vein) isintegral to all nuclear medicine procedures requiring injectionof a radiopharmaceutical into a vein. CPT code 36000 is notseparately reportable with these types of nuclear medicineprocedures. However, CPT code 36000 may be reported alone ifthe only service provided is the introduction of a needle into avein.) Other integral services do not have specific CPT codes.(For example, wound irrigation is integral to the treatment ofall wounds and does not have a HCPCS/CPT code.) Servicesintegral to HCPCS/CPT code defined procedures are included inthose procedures based upon the standards of medical/surgicalpractice. It is inappropriate to separately report servicesthat are integral to another procedure with that procedure.Many NCCI PTP edits are based upon the standards ofmedical/surgical practice. Services that are integral toanother service are component parts of the more comprehensiveservice. When integral component services have their ownHCPCS/CPT codes, NCCI PTP edits place the comprehensive servicein Column One and the component service in Column Two. Since acomponent service integral to a comprehensive service is notseparately reportable, the Column Two code is not separatelyreportable with the Column One code.Some services are integral to large numbers of procedures.Other services are integral to a more limited number ofprocedures. Examples of services integral to a large number ofprocedures include: Cleansing, shaving and prepping of skin;Draping and positioning of patient;Insertion of intravenous access for medicationRevision Date (Medicaid): 1/1/2021I-9
administration;Insertion of urinary catheter;Sedative administration by the physician performing aprocedure (see Chapter II, Anesthesia Services);Local, topical or regional anesthesia administered by thephysician performing the procedure;Surgical approach including identification of anatomicallandmarks, incision, evaluation of the surgical field,debridement of traumatized tissue, lysis of adhesions, andisolation of structures limiting access to the surgicalfield such as bone, blood vessels, nerve, and musclesincluding stimulation for identification or monitoring;Surgical cultures;Wound irrigation;Insertion and removal of drains, suction devices, and pumpsinto same site;Surgical closure and dressings;Application, management, and removal of postoperativedressings and analgesic devices;Application of TENS unit;Institution of Patient Controlled Anesthesia;Preoperative, intraoperative and postoperativedocumentation, including photographs, drawings, dictation,or transcription as necessary to document the servicesprovided;Imaging and/or ultrasound guidance;Surgical supplies, except for specific situations wherestate Medicaid policy permits separate payment.Although other chapters in this Manual further address issuesrelated to the standards of medical/surgical practice for theprocedures covered by that chapter, it is not possible becauseof space limitations to discuss all NCCI PTP edits based uponthe principle of the standards of medical/surgical practice dueto space limitations. However, there are several generalprinciples that can be applied to the edits as follows:1. The component service is an accepted standard of care whenperforming the comprehensive service.2. The component service is usually necessary to complete thecomprehensive service.3. The component service is not a separately distinguishableprocedure when performed with the comprehensive service.Revision Date (Medicaid): 1/1/2021I-10
Specific examples of services that are not separately reportablebecause they are components of more comprehensive servicesfollow:Medical:1. Since interpretation of cardiac rhythm is an integralcomponent of the interpretation of an electrocardiogram, arhythm strip is not separately reportable.2. Since determination of ankle/brachial indices requires bothupper and lower extremity Doppler studies, an upperextremity Doppler study is not separately reportable.3. Since a cardiac stress test includes multipleelectrocardiograms, an electrocardiogram is not separatelyreportable.Surgical:1.Since a myringotomy requires access to the tympanicmembrane through the external auditory canal, removal ofimpacted cerumen from the external auditory canal is notseparately reportable.2.A “scout” bronchoscopy to assess the surgical field,anatomic landmarks, extent of disease, etc., is not separatelyreportable with an open pulmonary procedure such as a pulmonarylobectomy. By contrast, an initial diagnostic bronchoscopy isseparately reportable. If the diagnostic bronchoscopy isperformed at the same patient encounter as the open pulmonaryprocedure and does not duplicate an earlier diagnosticbronchoscopy by the same or another physician, the diagnosticbronchoscopy may be reported with modifier 58 appended to theopen pulmonary procedure code to indicate a staged procedure. Acursory examination of the upper airway during a bronchoscopywith the bronchoscope shall not be reported separately as alaryngoscopy. However, separate endoscopies of anatomicallydistinct areas with different endoscopes may be reportedseparately (e.g., thoracoscopy and mediastinoscopy).3.If an endoscopic procedure is performed at the same patientencounter as a non-endoscopic procedure to ensure nointraoperative injury occurred or verify the procedure wasperformed correctly, the endoscopic procedure is not separatelyreportable with the non-endoscopic procedure.Revision Date (Medicaid): 1/1/2021I-11
4.Since a colectomy requires exposure of the colon, thelaparotomy and adhesiolysis to expose the colon are notseparately reportable.C.Medical/Surgical PackageMost medical and surgical procedures include pre-procedure,intra-procedure, and post-procedure work. When multipleprocedures are performed at the same patient encounter, there isoften overlap of the pre-procedure and post-procedure work.Payment methodologies for surgical procedures account for theoverlap of the pre-procedure and post-p
Jan 01, 2021 · CPT code 19301 (Mastectomy, partial.) plus CPT code 38745 (Axillary lymphadenectomy; complete). Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. For example, if a physician performs a superficial axillary lymphadenecto
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A number of diagnostic radiology procedures are subject to National Correct Coding Initiative (NCCI) edits. To process correctly, claims submitted for multiple diagnostic radiology procedures on the same day may require addition of an NCCI-associated modifier. Information about NCCI-associated modifiers is included in the Correct Coding Initiative:
"to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims," according to the National Correct Coding Initiative Policy Manual for Medicare Services (NCCI Manual). The NCCI is maintained by a CMS contractor, Correct Coding Solutions, LLC. The
If you have any questions regarding this letter, please call our Customer Service Center at 800-NCCI-123 (800-622-4123) and select the Experience Rating option, or email our Customer Service Center at customer_service@ncci.com.
As of July 31, 2021, NCCI tracked 939 state and federal workers compensation-related bills, including 577 bills in states where NCCI provides ratemaking services. To date, 150 bills have been enacted. . Utah, Vermont, Wisconsin, and Wyoming). Many of the COVID-19 workers compensation presumptions were
Procedure Coding System (HCPCS), ICD-10 CM and PCS, National Drug Codes (NDC), Diagnosis Related Group (DRG) guidelines, Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) Policy Manual, CCI table edits and other CMS guidelines. Claims are subject to the code edit protocols for services/procedures billed.
Version 16.3 x supersede any other CMS national coding, coverage, or payment policies. Policy Manual Background The National Correct Coding Initiative Policy Manual for Medicare Services and NCCI edits have been developed for application to Medicare services billed by a single provider for a single patient
How to Use the Medicare National Correct Coding Initiative (NCCI) Tools MLN Booklet Page 4 of 18 MLN901346 January 2021 (SNFs)), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech-language pathology providers (OPTs), and
