CurrentFlorida BluePolicy 10-006

NCCI (Procedure-to-Procedure) Coding Edits Payment Policy

Defines Florida Blue's application of CMS NCCI PTP coding edits for professional and facility claims and explains modifier usage to report services together; applies to all lines of business and providers billing Florida Blue.

Policy Summary

PayerFlorida Blue

PolicyNCCI (Procedure-to-Procedure) Coding Edits Payment Policy

Policy CodePolicy 10-006

Change TypeNo material change

Effective DateJul 10, 2025

Next Review DateN/A

Key ActionWhen column-one and column-two codes are submitted together, report a recognized modifier when permitted to avoid denial of the column-two code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCCI PTP edits appliedtype of edits

CMS-1500, UB-04claim form types

0 or 1modifier indicators

23-081related policy

NCCI Procedure-to-Procedure (PTP) Billing and Payment Rules

NCCI PTP billing/payment criteria

When two codes in an NCCI PTP edit pair are reported by the same provider for the same member on the same date of service:

If column-one and column-two codes from an NCCI PTP edit pair are submitted together by the same provider for the same member on the same date of service, column-two is denied and column-one is eligible for payment unless an allowed modifier is properly reported.

Each NCCI PTP edit has a modifier indicator: a value of '0' indicates a modifier cannot be used to bypass the edit; a value of '1' indicates a properly reported recognized modifier may permit bypass of the edit.

Recognized modifiers that may be used, when clinically appropriate and when the edit's modifier indicator allows (indicator = '1'), include evaluation/management and distinct-procedure modifiers and a set of anatomic and X‑modifiers (examples: 25, 59, XE, XP, XS, XU, LT, RT and specified E-, F-, T- modifiers).

Policy applies to professional (CMS-1500) and facility (UB-04) billing and to all lines of business and providers of service; Florida Blue applies these NCCI PTP edits to determine separate reimbursement.

Policy Summary

PayerFlorida Blue

PolicyNCCI (Procedure-to-Procedure) Coding Edits Payment Policy

Policy CodePolicy 10-006

Change TypeNo material change

Effective DateJul 10, 2025

Next Review DateN/A

Key ActionWhen column-one and column-two codes are submitted together, report a recognized modifier when permitted to avoid denial of the column-two code.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Edit Pairs, Modifiers, and Indicator Requirements

NCCI PTP Edit Pairs (overview)mixed

NCCI PTP

Column-one/column-two edit pairs applied to CPT/HCPCS to determine reimbursement; column-two denied when paired unless allowed by recognized modifier and modifier indicator permits bypass.

Recognized Modifiers (may bypass PTP when modifier indicator = 1)ModifierCovered

25	Significant, Separately Identifiable Evaluation and Management Service by the same physician on the same day of the procedure or other service.
59	Distinct Procedural Service.
XE	Separate Encounter - service distinct because it occurred during a separate encounter.
XP	Separate Practitioner - service distinct because performed by a different practitioner.
XS	Separate Structure - service distinct because performed on a separate organ/structure.
XU	Unusual Non-Overlapping Service - distinct because it does not overlap usual components of the main service.
LT	Left side (used to identify procedures performed on the left side of the body).
RT	Right side.
E1	Upper left eyelid.
E2	Lower left eyelid.

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Modifiers Not Permitting Bypass (modifier indicator = 0)ModifierNot Covered

Modifier indicator 0

For edits assigned modifier indicator '0', no modifier will bypass the column-one/column-two edit; column-two code will be denied when reported with column-one.

Recognized Anatomic & Procedural ModifiersModifierCovered

25	Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day as the Procedure or Other Service.
59	Distinct Procedural Service.
XE	Separate Encounter - distinct because it occurred during a separate encounter.
XP	Separate Practitioner - distinct because performed by a different practitioner.
XS	Separate Structure - distinct because performed on a separate organ/structure.
XU	Unusual Non-Overlapping Service - distinct because it does not overlap usual components of the main service.

Anatomic/Location Modifiers (site-specific)ModifierCovered

LT	Left side.
RT	Right side.
E1	Upper left eyelid.
E2	Lower left eyelid.
E3	Upper right eyelid.
E4	Lower right eyelid.
FA	Left hand - thumb.
F1	Left hand - digit (as applicable).
F2	Left hand - third digit.
F3	Left hand - fourth digit.

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Notes on Modifier Usemixed

General

Modifiers listed may be used to bypass NCCI PTP edits only when the specific edit's modifier indicator = 1 and clinical documentation supports distinct service. Florida Blue will not reimburse column-two codes unless correctly reported with one of the recognized modifiers and supporting documentation.

inv-04: Modifier indicator requirement — explains modifier indicator '1' vs '0' and bypass rules

Modifier indicator '1'Indicates a properly coded associated modifier may be used to bypass the NCCI PTP edit when supported by documentation; column-two code may be reimbursed if modifier is valid for that edit and clinical circumstances justify separate service.

Modifier indicator '0'Indicates no modifier will bypass the edit; column-two code will be denied when reported with column-one.

Bypass rulesFlorida Blue will only allow bypass when (1) the NCCI edit’s modifier indicator = 1, (2) one of the recognized modifiers is appended, and (3) documentation substantiates the distinct service. Modifiers cannot be used to bypass edits assigned indicator = 0.

Provider Billing and Reimbursement Responsibilities

Note

Important Notice

THIS PAYMENT POLICY IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT. IT DOES NOT CONSTITUTE MEDICAL ADVICE. All medical decisions are the responsibility of the patient and treating physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. Legislative mandates, provider contract documents, or the member's benefit coverage may supersede this policy.

Billing Rule

NCCI PTP Edits Applied

Provider billing and reimbursement actions — Florida Blue applies NCCI Procedure-to-Procedure (PTP) coding edits to professional claims. Each NCCI PTP edit pairs two CPT and/or HCPCS codes (column-one and column-two). When both codes of an edit pair are reported by the same provider for the same member on the same date of service, the column-two code will be denied and the column-one code is eligible for payment unless the column-two code is appropriately reported with one of the NCCI-designated modifiers recognized by Florida Blue.

Uses the column-one/column-two NCCI edits to determine separate reimbursement eligibility on professional claims
Column-two codes are denied when reported with column-one by same provider/member/date of service unless bypassed by approved modifier

Prior Authorization

Modifier Indicators

Modifier use and restrictions — each NCCI PTP edit has a modifier indicator. Modifier indicator "0" means no modifier may be used to bypass the edit. Modifier indicator "1" means a properly coded associated modifier can be used to allow separate payment for the column-two code. Florida Blue will not reimburse column-two codes separately unless the codes are correctly reported with one of the recognized modifiers and the clinical circumstances justify modifier application.

Modifier indicator = 0: modifier cannot be used to bypass the edit
Modifier indicator = 1: properly reported modifier may bypass the edit when clinically supported
Florida Blue requires correct reporting and clinical justification for modifier use to permit separate reimbursement

Documentation Required

Recognized Modifiers and Documentation

Recognized modifiers that may be used, when clinically appropriate, to bypass an NCCI PTP edit include anatomic modifiers and other NCCI-designated modifiers. Providers must report the applicable modifier(s) on the claim and retain supporting clinical documentation in the medical record to justify separate payment. Lack of appropriate modifier reporting or insufficient documentation may result in denial or recoupment.

Examples: anatomic modifiers and other NCCI-designated modifiers (use per NCCI guidance)
Provider must include modifier on claim and maintain supporting clinical documentation in the medical record
Insufficient modifier use or documentation may lead to denial or recoupment

Terms and Edit Concepts

NCCI (National Correct Coding Initiative)

DefinitionNational Correct Coding Initiative (NCCI) — CMS program developed to promote correct coding methodologies and to control improper coding that would lead to inappropriate payment; NCCI edits are a recognized industry source for relationships between codes.

Basis for editsNCCI coding policies are based on CPT conventions, national/local policies, society guidelines, analysis of standard medical and surgical practices, and review of current coding practices.

Application to claimsThis policy applies to services billed on CMS-1500 (professional) or UB-04 (facility) claim forms.

Edit structureNCCI Procedure-to-Procedure (PTP) edits are organized as column-one/column-two pairs; when both codes are reported together the column-two is generally denied unless a permitted modifier allows separate reimbursement.

Column-one / column-two edit

Edit descriptionColumn-one/column-two PTP edit — each edit pair contains a column-one and column-two HCPCS/CPT code; when both are reported by the same provider for the same member on the same date of service, the column-two code is denied and the column-one code is eligible for payment unless properly reported with a recognized modifier.

Denial ruleColumn-two is denied when reported with column-one unless an allowed modifier is present and the edit's modifier indicator permits bypass.

Modifier dependencePermitted modifiers can allow separate reimbursement for the column-two code only when the edit's modifier indicator equals '1' and the modifier is one recognized by Florida Blue.

PurposeThese edits identify services that in general should not be reported together and help ensure appropriate payment determinations.