CurrentMedicarePolicy N/A

National Correct Coding Initiative (NCCI) Policy Manual — NCCI PTP, MUE, and AOC Guidance

National Medicare policy describing NCCI program structure, edit types (PTP, MUE, AOC), development/review processes, and use by Medicare contractors to promote correct coding and control improper Part B payments; affects Medicare providers, suppliers, and Medicare Administrative Contractors (MACs).

Policy Summary

PayerMedicare

PolicyNational Correct Coding Initiative (NCCI) Policy Manual

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders should apply NCCI PTP edits and MUE rules when submitting Part B claims and use appropriate modifiers only when documentation supports separate reporting.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3edit types in NCCI program (PTP, MUE, AOC)

4NCCI versions published annually

13narrative chapters

1/1/2026document revision date

MACs/QICsappeals routing

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.

Coverage, Bundling, and MUE Adjudication Rules

inv-01: NCCI coverage and adjudication rules — how NCCI edits are applied to claims

NCCI PTP edits are Medicare claims processing contractor tools used to adjudicate practitioner, outpatient hospital, and certain outpatient therapy claims by applying correct coding and bundling rules. They do not apply to inpatient facility claims. CPT codes denied by NCCI PTP edits may not be billed to Medicare beneficiaries, and denials based on incorrect coding cannot be bypassed with an Advanced Beneficiary Notice (ABN). CMS and Medicaid maintain separate NCCI edit files and manuals; in Medicare references the term 'physician' generally applies to all practitioners or suppliers eligible to bill the HCPCS/CPT codes unless otherwise specified.

NCCI PTP edits identify HCPCS/CPT code pairs (Column One/Column Two) that generally should not be reported together for the same patient encounter and same anatomic site unless specific modifier or clinical criteria are met.

Claims processing contractors use NCCI PTP-associated modifiers to permit reporting of both codes of an edit only when the edit's modifier indicator allows it and the documentation supports separate encounters, distinct anatomic sites, or other valid modifier rationale.

Providers/suppliers must follow Medicare Internet-Only Manual (IOM) and NCCI tool guidance when reporting services under OPPS; CPT codes denied by NCCI PTP edits may not be billed to beneficiaries because denials are coding-based, not medical-necessity based.

inv-02: Medicare coding & billing constraints — general correct coding rules that affect coverage/payment determinations

General correct coding principles govern when HCPCS/CPT codes must be reported as the single comprehensive code versus fragmented or additional component codes. Providers/suppliers must select codes that accurately describe all services performed, avoid fragmenting comprehensive services into components, and report correct units of service.

A provider/supplier shall report the HCPCS/CPT code that most accurately and comprehensively describes the services performed rather than reporting a less comprehensive code plus additional codes to approximate the comprehensive service.

Do not fragment a procedure into component parts or unbundle a bilateral procedure into two unilateral codes when a single code or defined bilateral reporting (modifier 50 or LT/RT) is required.

Biopsy reporting: report a biopsy separately only when pathologic examination results in an immediate decision to proceed with a more extensive procedure on the same lesion or when the biopsy is performed on a separate lesion; do not report biopsies performed to assess resection margins or to verify resectability separately.

Units of service (UOS) must reflect the CPT-defined unit — e.g., per 15-minute therapy increments versus per session codes — and providers shall not misuse timing or session-based reporting.

inv-03: Bundling and separate reporting criteria — coverage stance for same-day services and component reporting under NCCI PTP

Many component services are considered part of a comprehensive procedure or the global surgical package and are therefore not separately reportable. NCCI PTP and Global Surgery/Anesthesia rules define when same-day services are bundled or may be reported separately with appropriate modifiers.

Standards of medical/surgical practice list common included components (e.g., prepping, draping, IV access, insertion/removal of drains, wound irrigation, surgical closure, intraoperative documentation, imaging guidance, routine supplies). These components are usually: (1) accepted standard of care when performing the comprehensive service; (2) usually necessary to complete the comprehensive service; and (3) not separately distinguishable when performed with the comprehensive service.

Medical/surgical package: pre-, intra-, and post-procedure work is included in surgical payment; airway and intravenous access for procedures are typically included and not separately reportable. Elective endotracheal intubation is not separately reportable (CPT 31500 describes emergency intubation only).

Anesthesia: Medicare prevents separate payment for anesthesia services performed by the same physician performing the procedure except in limited circumstances; anesthesia CPT ranges (00100-01999 and related codes) and components (e.g., venipuncture, drug administration) are generally included in the procedure payment. Moderate conscious sedation (99151-99157) may be separately reportable when not bundled into the procedure.

inv-04: Bundling and modifier criteria — rules determining when procedures are bundled versus separately reportable and when modifiers may bypass edits

Modifier use is tightly constrained: NCCI PTP-associated modifiers permit bypassing an edit only when the specific edit allows the modifier and supporting documentation demonstrates the modifier's criteria are met (different encounter, distinct anatomic site, distinct lesion, or distinct timed service blocks).

Modifiers 59, XE, XP, XS, and XU are NCCI PTP-associated modifiers; they shall not be used to bypass an edit unless proper criteria for the selected modifier are met and documented in the medical record.

Common misuses: applying modifier 59 solely because two codes describe different procedures; using different diagnoses alone is not sufficient justification for modifier use.

Special modifier scenarios: (1) diagnostic procedure preceding or following a therapeutic procedure may be separately reportable if it meets timing and clinical necessity constraints (e.g., not interspersed with therapeutic services and clearly the basis for the therapeutic decision); (2) timed services may be reported separately with modifier 59 when separate distinct time blocks exist for distinct timed services, provided total time and UOS rules are met; (3) reporting for different anatomic sites requires distinction of different organs, anatomic regions, or non-contiguous lesions in same organ, not contiguous structures.

inv-05: MUE adjudication and coverage stance — key coverage and adjudication principles regarding MUEs and edits

Medically Unlikely Edits (MUEs) set maximum UOS for a HCPCS/CPT code per claim line or per date of service to reduce paid-claims error. MUEs are coding edits (not coverage determinations) and are enforced by MACs, DME MACs, and facility claim adjudication processes.

An MUE defines the maximum UOS expected for the vast majority of correctly reported claims for the same provider/supplier, same beneficiary, and same date of service.

MUE adjudication types: claim-line MUEs (UOS compared per claim line) and date-of-service (DOS) MUEs (all UOS for same code and DOS are summed across claim lines and compared to the MUE). If UOS exceed the MUE, the relevant UOS are denied; DOS MUEs deny all UOS for that code on that date if the summed UOS exceed the MUE.

MUE values may be assigned MAI indicators (e.g., MAI '2' indicates a processing restriction not to be overridden; MAI '3' permits contractor bypass if medical review finds services were provided and medically necessary).

MUEs do not determine coverage; they are coding edits and may be more or less restrictive than contractor-specific edits. Providers should confirm correct code use, correct UOS counting, and medical necessity if encountering frequent MUE denials.

inv-06: MUE and contractor application criteria — claims and reporting rules tied to MUEs and contractor edits

Operational guidance and contractor application: MUEs and NCCI PTP edits are not utilization limits but coding controls. Contractors may implement more restrictive edits; some MUE values are confidential and not published.

Providers should not structure care across multiple dates solely to avoid MUEs or NCCI edits; performing services on different dates to circumvent edits is not permitted.

Bilateral procedure reporting: report bilateral surgical procedures with modifier 50 and one unit of service unless the CPT descriptor defines the code as 'bilateral' (then report one unit without modifier 50). ASCs should report bilateral procedures on two lines with LT/RT modifiers. Contractor-specific practices (e.g., allowing reporting across date spans) require 'from'/'to' dates and contractor rules for dividing UOS for MUE comparison.

Some MUE values are confidential; most MUEs are published on CMS MUE webpages but not all. If a contractor edit is more restrictive than the MUE, the more restrictive edit applies.

inv-07: Anesthesia reporting and separate payment rules — anesthesia coding payment and separate reporting criteria

Anesthesia coding and payment follow Medicare's anesthesia rules: anesthesia codes usually include preoperative evaluation, administration of anesthetic agents, monitoring, and routine postoperative evaluation — with time-based units and specific reporting constraints when anesthesia and procedure are furnished by the same clinician.

Anesthesia CPT ranges (00100-01999; related codes) describe anesthesia for surgical interventions; generally only one anesthesia code is reported per anesthesia session unless an Add-On Code applies.

Anesthesia time is reported as continuous time the anesthesia practitioner is present; time-based reporting and aggregation rules apply including treatment of interruptions and allocation of total time for multiple related timed services.

When the physician performing the procedure provides anesthesia, separate anesthesia CPTs generally are not payable; components bundled into anesthesia (e.g., venipuncture, IV infusions, monitoring) shall not be separately reported by that physician.

Exceptions: moderate (conscious) sedation codes (99151-99157) may be separately reportable in some circumstances; certain postoperative epidural or peripheral nerve block management codes may be separately reportable on postoperative dates or when intraoperative anesthesia adequacy is not dependent on the block. Documentation must support separate reporting and appropriate modifiers (e.g., 59, XU) where required.

inv-08: Separate reporting and inclusion criteria — rules determining when services are included in global payments versus separately reportable

Global Surgery and specialty-specific rules determine inclusion or exclusion of related services. Many commonly performed adjuncts (dressings, local anesthesia, drains, routine imaging guidance) are included in surgical codes; specialty chapters (e.g., integumentary, breast, Mohs) list specific mutually exclusive and bundled relationships.

Global periods: procedures carry global periods (000/010/090/XXX/YYY/ZZZ/MMM) that affect E&M reporting on the same date of service; decision-to-operate E&M for major procedures may be reported with modifier 57; significant separate E&M unrelated to the procedure may be reported with modifier 25.

Included services common to surgery: supplies, local anesthesia, routine monitoring, wound closure, and many intraoperative adjuncts are included in procedure payments and not separately reportable; under OPPS many of these items are also included.

Integumentary specifics: biopsies may be included in excision codes unless performed on a separate lesion or staged (modifier 58 may apply); Mohs codes include pathology and certain biopsy services; lesion removal, intralesional injections for anesthesia, and debridement may be bundled depending on lesion/site.

Breast surgery: mastectomy codes include removal of breast tissue and lesions and often include incision and closure; sentinel lymph node biopsy is separately reportable in some circumstances; reconstruction code relationships with implant insertion, flaps, and grafts are specified.

inv-09: Coverage and billing rules — governing when services are included in procedure payment and when separate reporting is allowed or disallowed

Coverage and billing rules across systems reiterate core NCCI themes: included components, modifier constraints, global surgery interactions, and system-specific bundling examples (arthroscopy, spine, musculoskeletal).

Fluoroscopy, radiologic, and ultrasound guidance described as included in a procedure by the code descriptor are not separately reportable; if an additional distinct procedure requires separate guidance, that guidance code may be reported with an appropriate NCCI modifier.

E&M interactions: E&M services in global periods follow the global surgery rules — modifier 57 for preoperative decision for major surgery, modifier 25 for significant unrelated E&M with minor procedures, and modifier 24 for unrelated postoperative E&M during the global period.

Anesthesia and drug administration: anesthesia and many drug administration services related to operative procedures are included in the procedural code; certain non-anesthesia drug services in nonfacility settings may be separately reportable with appropriate modifiers.

Arthroscopy/spine/musculoskeletal specifics: diagnostic arthroscopy is included in surgical arthroscopy; arthroscopic debridement rules and exceptions (knee/shoulder) are detailed; spinal exploration, instrumentation and arthrodesis include manipulation and monitoring as included components; only one anterior/posterior instrumentation code per skin incision is payable.

inv-10: Bundling and reporting criteria (musculoskeletal/spine) — billing/coverage criteria and specific rules

Musculoskeletal and spine chapters provide numerous examples where exploration, monitoring, and adjunct services are integral and not separately payable, while also specifying circumstances where separate reporting is allowed with modifiers or when performed by a different provider.

Exploration of the surgical field is standard practice and not separately reportable with other procedures in that field unless performed in a different anatomic area (modifier 59/XS may apply).

Intraoperative neurophysiology monitoring is included in the global package when performed by the physician performing the procedure; it is separately reportable only when performed by a different physician.

Spinal procedures: many spinal arthrodesis and instrumentation codes include manipulation and exploration; CPT 22505 (manipulation of spine) and certain exploration codes are not separately reportable when part of other spine procedures. Instrumentation and interbody device insertion have rules about included anterior instrumentation versus additional unrelated instrumentation reportable with modifiers.

MUE considerations for musculoskeletal codes: certain codes have MAI/MUE constraints (e.g., implant removal units, graft codes limited to one unit per procedure, finger/toe modifiers for multiple-site reporting).

inv-11: COVERAGE CRITERIA — general stance: many services included in surgical/procedural codes and not separately reimbursable unless explicitly allowed

General coverage stance: most services that are integral, standard, or necessary components of more comprehensive procedures are not separately reportable. Multiple system-specific examples illustrate how to apply the inclusion principle across respiratory, thoracic, cardiovascular, abdominal, laparoscopic, and other surgical domains.

Included components: debridement, exploration, intraoperative imaging, wound closure, device procurement, hemodynamic monitoring, and routine postoperative care are typically included in primary procedure codes and not separately billable.

Respiratory/thoracic: diagnostic endoscopy is not separately reportable with surgical endoscopy; endoscopic procedures performed to confirm adequacy or lack of injury during open procedures are not separately reportable; chest radiographs to confirm tube placement or intubation are not separately reportable.

Cardiovascular: graft procurement, cannulation for cardiopulmonary bypass, and intraoperative imaging/guidance integral to bypass or device procedures are included; diagnostic angiography performed as part of an interventional procedure is generally included unless specifically distinct and documented.

Abdominal/laparoscopy: exploration, incidental organ removal (e.g., gallbladder during hepatectomy), and laparoscopic components integral to open procedures are not separately reportable; some distinct diagnostic procedures may be reported if they drive the decision to operate and meet staging modifier rules.

inv-12: NCCI billing and bundling criteria (excerpt) — key billing/coverage criteria and examples from this fragment

NCCI PTP billing and bundling criteria are illustrated with extensive code-pair examples and policy rationales across specialties; when in doubt, select the most comprehensive code, use modifiers only per guidance, and ensure documentation supports any bypass of edits.

When diagnostic procedures lead to therapeutic interventions on the same encounter, diagnostic codes may be reportable only if they were the basis for the therapeutic decision and meet timing/documentation constraints (modifiers 57/58 as applicable).

Code family rules: indented CPT code families share descriptors; the primary parent code often includes components common to indented codes and may preclude separate reporting of the indented codes unless performed on contralateral sites or separate encounters.

Separate procedure designation: codes labeled 'separate procedure' are not separately reportable when performed through the same incision/orifice/approach as another anatomically related procedure.

Timing and conversion: if an endoscopic/laparoscopic procedure is converted to open, the endoscopic/laparoscopic codes generally are not separately reportable with the open procedure; staged procedures may use modifiers to denote planned sequencing when appropriate.

inv-13: Non-separately reportable and conditional reporting rules — when procedures/services are not separately reportable

Non-separately reportable items and conditional reporting rules emphasize that included imaging, guidance, or ancillary procedures are not separately payable unless explicitly excluded or performed for a distinct, necessary purpose documented in the medical record.

If a code descriptor or CPT instruction includes radiologic guidance or imaging, that guidance is included and not separately reportable; separate imaging codes may be reported only for additional procedures requiring distinct guidance and with appropriate modifiers.

Endoscopic rules: lavage, fluoroscopy, and routine access-region evaluations performed as part of endoscopic procedures are included; when a diagnostic endoscopy drives the decision to perform a therapeutic open procedure, staging modifiers (e.g., 58) and documentation permit separate reporting.

Abdominal procedures: exploratory procedures, incidental organ removals, and enterolysis designated as 'separate procedures' are generally not reportable separately when performed through the same incision; exceptions exist when procedures are performed on separate noncontiguous sites or clearly distinct anatomic areas.

When multiple procedures are performed, report the most comprehensive code(s); append modifier 51 for multiple secondary procedures and ensure documentation supports clinical necessity and distinctness.

inv-14: Bundling and separate-reporting criteria (excerpts) — guidance when codes are considered included in other procedures and when separate reporting allowed

Bundling and separate-reporting criteria are reiterated across abdominal, endoscopic, laparoscopic, cardiovascular, and other procedural areas. The manual provides specific code-level guidance for when codes are mutually exclusive, included, or may be reported with modifiers and when MUEs limit units of service.

Endoscopic services: surgical endoscopy includes diagnostic endoscopy; diagnostic endoscopy may be separately reportable only when it clearly results in the decision to perform a subsequent therapeutic procedure. Fluoroscopy and other imaging integral to endoscopy are included and not separately reportable.

Abdominal and laparoscopic procedures: many laparoscopic and open abdominal services include exploration, lavage, and access maneuvers; specific codes (e.g., laparoscopic appendectomy) may be reported separately only when removal of a diseased appendix occurs and is medically necessary.

MUE supplemental rules: MUE values for dilation, ERCP duct dilation, and supply items are based on clinical benchmarks or defined units (e.g., per duct, per specimen) and should guide UOS reporting; reporting multiple lines or using modifiers to bypass MUEs frequently may indicate incorrect coding practices.

General: when two procedures are mutually exclusive or one is included in the descriptor of another, do not report both; use modifiers only when the edit allows and when documentation demonstrates distinctness by encounter, anatomic site, or timed service blocks.

Code Lists, MUEs, and Edit Types

Included/Integral Vascular Access & FluoroscopyCPT

36000	Introduction of needle or intracatheter into a vein (integral to anesthesia or procedures)
36400	Venipuncture, age 3 years or older (not separately reportable when related to procedure)
36410	Collection of venous blood by venipuncture (not separately reportable when related to procedure)
77001	Fluoroscopic guidance for central venous access device; not separately reportable with many procedures
76000	Fluoroscopy; general (integral to many endoscopic/arthroscopic/laparoscopic procedures)
77002	Fluoroscopic guidance for catheter placement (not separately reportable when integral)

Modifiers - NCCI-associated and Non-bypassModifier

24	Unrelated E/M during postoperative period (global surgery modifier)
25	Significant, separately identifiable E/M on same day of procedure
57	Decision for surgery - preoperative E/M (global surgery modifier)
58	Staged or related procedure during postoperative period
78	Unplanned return to OR for related procedure (postoperative)
79	Unrelated procedure or service by same physician during postoperative period
59	Distinct procedural service (use carefully; many cases prefer XE/XS/XP/XU)
91	Repeat clinical diagnostic laboratory test
XE	Separate Encounter
XS	Separate Structure

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Add-on & Critical Care AOC / NeurophysiologyCPT

95940	Continuous intraoperative neurophysiology monitoring; bundled if performed by operating physician
95941	Continuous intraoperative neurophysiology monitoring, add-on
G0453	Intraoperative neurophysiology monitoring; add-on (Type I AOC example)
99291	Critical care, first 30-74 minutes (primary for AOC 99292)
99292	Critical care, each additional 30 minutes (AOC to 99291)

Pathology / Mohs / Surgical PathologyCPT

17311	Mohs micrographic surgery, first stage (skin cancer)
17312	Mohs micrographic surgery, subsequent stages
17313	Mohs micrographic surgery, repair/reconstruction included separately when performed
17314	Mohs micrographic surgery codes range (17311-17315)
17315	Mohs micrographic surgery codes range
88300	Surgical pathology, gross and microscopic examination; Level I
88301	Surgical pathology, Level II
88302	Surgical pathology
88304	Surgical pathology
88305	Level IV surgical pathology

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Injection / Drug Administration / Specimen CodesCPT

11900	Intralesional injection; single lesion, non-chemotherapeutic
11901	Intralesional injection; multiple lesions
96405	Intralesional chemotherapy; single lesion
96406	Intralesional chemotherapy; multiple lesions
96360	IV infusion, hydration; bundled into many procedures
96361	IV infusion/add-on (examples of 96360-96379 range)

Arthroscopy / Knee / ShoulderCPT

29822	Arthroscopy, shoulder; limited debridement (included in many shoulder procedures)
29823	Arthroscopy, shoulder; extensive debridement (generally included except 3 exceptions)
29824	Arthroscopy, shoulder; distal claviculectomy (may be separately reportable with 29823 if different area)
29827	Arthroscopy, shoulder; with rotator cuff repair (may be separately reportable with 29823 if different area)
29828	Arthroscopy, shoulder; biceps tenodesis (may be separately reportable with 29823 if different area)
29874	Knee arthroscopy; removal of loose body (included with many knee arthroscopy codes)
29875	Knee arthroscopy; limited synovectomy (separate procedure)
29876	Knee arthroscopy; major synovectomy
29877	Knee arthroscopy; chondroplasty/debridement (included in many codes)
29880	Knee arthroscopy; meniscectomy medial AND lateral (includes chondroplasty)

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Spine / Arthrodesis / MonitoringCPT

22532	Arthrodesis, lateral extracavitary technique, single thoracic segment (family 22532-22534)
22533	Arthrodesis, lateral extracavitary technique, single lumbar segment
22534	Arthrodesis, lateral extracavitary technique; add-on for each additional segment
22630	Arthrodesis, posterior interbody technique, single interspace; lumbar
22633	Arthrodesis by combined posterior/ interbody technique
22665	Other spinal fusion family codes (examples included in range 22532-22665)
22830	Exploration of spinal fusion (not separately reportable in same area)
22505	Manipulation of spine requiring anesthesia; not separately reportable with many spine procedures
38222	Diagnostic bone marrow; biopsy and aspiration (may be billed instead of separate aspiration/biopsy codes)

Fracture / Cast / Manipulation / ImplantsCPT

20650	Removal of implanted devices with skeletal traction (separate procedure designation - unit rules)
20670	Removal of implanted hardware; superficial (unit of service = anatomic site)
20680	Removal of implanted hardware; deep (unit of service = anatomic site)
21497	Interdental wiring (not separately reportable with facial procedures)
97140	Manual therapy techniques; may require modifier 59/XE/XS/XU to indicate distinct service from compression systems

Wound Care / Debridement / RepairsCPT

97014	Application of a modality to one or more areas; electrical stimulation (not separately reportable for bone healing if other codes apply)
97032	Application of modality; electrical stimulation (unattended)
11010	Debridement; skin, partial thickness (may be included in other procedures)
11011	Debridement; skin, full thickness
11012	Debridement; skin, extensive
11042	Debridement including muscle and/or bone (not separately reportable when in surgical field)
11043	Debridement including bone (example codes 11043-11047 are not separately reportable when in surgical field)
11044	(See 11043-11047 family)
11045	Debridement superficial
11046	Debridement deep with muscle involvement

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Biopsy / FNA / Pathology Unit RulesCPT

10004	Fine needle aspiration; including imaging guidance - unit is per separately identifiable lesion
10005	Fine needle aspiration with imaging guidance
10012	Fine needle aspiration with interpretation and report
10021	FNA without imaging guidance (core FNA)
10004-10012	FNA family; one unit per lesion; multiple passes into same lesion = one unit
36591	Collection of blood specimen from implantable venous access device (only with lab service)
36592	Collection of blood specimen using established central or peripheral catheter (only with lab service)

ENT / Nasal / Sinus / EndoscopyCPT

31256	Nasal/sinus endoscopy with maxillary antrostomy (included in larger orbital decompression procedures when ipsilateral)
31267	Endoscopy with removal of tissue from maxillary sinus (included in larger procedures)
31276	Endoscopy with frontal sinus exploration (included in larger procedures)
31287	Endoscopy with sphenoidotomy
31288	Endoscopy with sphenoidotomy and removal of tissue
30130	Excision inferior turbinate; may be included when performed to access sinuses

Cardiac / Pacemaker / EPCPT

33202	Insertion of new or replacement of pacemaker/defibrillator pulse generator (family 33202-33275) - many related guidance/fluoroscopy services integral
33210	Insertion or replacement of temporary transvenous single chamber cardiac electrode; not separately reportable with many device procedures
33211	Insertion or replacement of temporary transvenous dual chamber cardiac electrode; not separately reportable
93600	Intracardiac electrophysiologic evaluation (family 93600-93662) - fluoroscopy and catheter placement integral
93662	EP study with ablation (example end of family)

Upper GI / Colonoscopy / DilationCPT

43213	Esophagoscopy with dilation (dilation unit rules: includes dilation of all strictures in procedure; single unit)
45340	Sigmoidoscopy/colonoscopy dilation (unit-of-service rules apply)
45386	Colonoscopy with dilation (unit-of-service rules apply)
43277	ERCP with trans-endoscopic balloon dilation; unit = each duct (includes multiple strictures per duct)
43214	Esophagoscopy with dilation; other variants

Dermatologic / Lesion Removal / MohsCPT

11102	Biopsy of skin; not separately reportable with lesion removal of same lesion
11107	Biopsy codes family (11102-11107)
11400	Excision of benign lesion (family 11400-11471)
11600	Excision of malignant lesion (family 11600-11646)
12001-13153	Wound repair families (not separately reportable in many surgical contexts)
17311-17315	Mohs micrographic surgery (pathology included; do not report separate pathology codes)

Provider Billing Responsibilities, Modifier Use, and Appeals

Billing Rule

Claims adjudication and beneficiary billing restrictions

MACs apply NCCI Procedure-to-Procedure (PTP) edits when adjudicating Medicare Part B claims for practitioner services, outpatient hospital services, outpatient therapy services, ASCs, and other outpatient provider types; these PTP edits are not applied to inpatient facility claims. CPT codes denied by NCCI PTP edits may not be billed to Medicare beneficiaries, and an Advanced Beneficiary Notice (ABN) may not be used to shift liability for denials based on NCCI PTP edits.

Documentation Required

Reconsideration and Appeals Process

Providers may request reconsideration of a PTP edit, an MUE value, or an AOC edit by submitting a written request (with rationale and suggested change) to NCCIPTPMUE@cms.hhs.gov. Appeals of claim denials for NCCI-related edits must be submitted to the responsible MAC or QIC rather than to the NCCI contractor.

Key Terms and Acronyms

inv-103: NCCI PTP — Procedure-to-Procedure edits definition

DefinitionNCCI Procedure-to-Procedure (PTP) edits: paired HCPCS/CPT codes (Column One/Column Two) that generally should not be reported together; if both are reported for same beneficiary on same date, Column One is eligible for payment and Column Two is denied unless an appropriate NCCI PTP-associated modifier is allowed and reported.

Table structureAll NCCI PTP edits are consolidated into a single Column One/Column Two edit table (since April 1, 2012), simplifying research and application.

PurposePrevent inappropriate payment of services that should not be reported together by enforcing bundling/misuse rules.

inv-104: MUE — Medically Unlikely Edits definition

DefinitionMedically Unlikely Edits (MUEs): CMS-established edit values limiting units of service for a HCPCS/CPT code per beneficiary per date of service to prevent inappropriate multiple reporting and overbilling.

Policy Summary

PayerMedicare

PolicyNational Correct Coding Initiative (NCCI) Policy Manual

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders should apply NCCI PTP edits and MUE rules when submitting Part B claims and use appropriate modifiers only when documentation supports separate reporting.

SourceLink

On This Page

Avoid upcoding (reporting a code whose descriptor includes services not actually performed) and downcoding (reporting a less comprehensive code plus other codes); report the code that reflects the full service performed.

E&M services: E&M on the same date as procedures with global periods 000/010/090 follow Global Surgery Rules — decision-to-operate visits for major procedures may be reported with modifier 57; significant and separate E&M unrelated to the procedure may be reported with modifier 25; postoperative visits related to the procedure are included in the global package.

Modifiers: NCCI PTP-associated modifiers (e.g., 59, XE, XP, XS, XU) shall not be used to bypass an edit unless proper criteria are met and documented. Misuse includes relying solely on the notion of 'different procedure or surgery' without documentation of separate encounter or anatomic site.

Definition of different anatomic site for NCCI: different organs, different anatomic regions, or different lesions in same organ (non-contiguous). Contiguous structures in same organ/region do not qualify as different sites for modifier rationale.

General policy: if a code descriptor includes 'separate procedure', CMS does not allow separate payment for that procedure when performed through the same incision/orifice/anatomic area as another procedure; many bilateral or laterality-related edits permit modifiers when procedures are performed on contralateral organs but generally not if ipsilateral or contiguous.

Modifier and anatomic specificity: many edits allowing modifiers are contingent on performance at distinct anatomic sites (different organs, non-contiguous lesions); contiguous structures do not qualify. Use of laterality modifiers (LT/RT) or modifier 50 follows CMS IOM reporting rules.

Billing Rule

Modifier use and MAC adjudication

Do not append NCCI PTP-associated modifiers solely to bypass an edit; modifiers may be used only when the clinical circumstances justify their use and Medicare restrictions (CCMI) permit bypass. MACs may allow modifier 22 in limited circumstances for unusual procedural services when edits block payment.

Documentation Required

Modifier use and documentation

Use NCCI PTP-associated modifiers (e.g., 59, XE, XP, XS, XU) only when the modifier's criteria are met and the medical record documents the rationale; MAC processing systems rely on these modifiers to allow payment when edits permit.

Billing Rule

Reporting diagnostic vs therapeutic and timed services

Diagnostic procedures performed before or after a therapeutic intervention may be reported separately only when they are not inherent to the therapeutic procedure and meet the timing/documentation criteria; for timed services, separate timed blocks may justify modifier 59, but different diagnoses alone do not justify modifier 59.

Billing Rule

Anesthesia bundling and separate reporting limits

Do not separately report anesthesia CPT codes when anesthesia is furnished by the same physician who performs the medical or surgical service; many component services (e.g., venipuncture, IV infusion) are included in anesthesia and are not separately reportable unless unrelated to anesthesia.

Denial Risk

Appeals and ABN guidance for MUE denials

Units of service (UOS) denied because they exceed an MUE may be appealed through the contractor appeals process; issuance of an ABN is not appropriate to shift liability for UOS denied based on an MUE.

Billing Rule

Modifier use with MUEs

For claim-line MUEs (MAI = 1), appropriate use of modifiers (e.g., 59, XE, XP, XS, XU, 76, 77, 91, or anatomic modifiers) may permit the same HCPCS/CPT code to be reported on separate claim lines; contractors may limit modifier use for specific codes.

Documentation Required

MUE appeal and contractor actions

When an MUE value is based on 'Data', appeals reviewers will verify that the correct code was reported, the correct units of service were counted, the reported units were actually performed, and that all units were medically reasonable and necessary; contractors may apply more restrictive UOS edits than published MUEs and providers should consult local contractors if denials are frequent.

Billing Rule

DME MAC billing and MUE interaction

DME MACs follow specific billing rules for supply items reported over multiple days; MUEs for DME/supply codes are based on maximum units per single date of service or maximum days allowed on a single claim line, and providers must still report only medically reasonable and necessary supplies.

Billing Rule

Add-on Code publication and MAC responsibilities

CMS publishes the Add-on Code (AOC) to primary code mappings annually (on or by January 1) and posts quarterly updates as needed; MACs must follow Type 1 AOC rules and may develop allowable primary code lists for Type 2 and Type 3 AOCs per CMS guidance.

Billing Rule

Anesthesia time reporting

Anesthesia time must be reported as the continuous time the anesthesia practitioner is present with the patient; contractors calculate payment using base units plus reported time units.

Billing Rule

Reporting E&M services with global surgery

E&M services may be separately reportable on the same day as procedures with global periods (000, 010, 090) only under limited circumstances; use modifier 57 for preoperative decision-for-surgery E&M with major (090) procedures and modifier 25 for significant, separately identifiable E&M with minor (000/010) or some XXX procedures.

Billing Rule

Anesthesia billing restrictions

Do not separately report anesthesia CPT codes (00100-01999, 62320-62327, 64400-64530) when the physician performing the procedure furnishes the anesthesia; moderate conscious sedation (99151-99153) may be separately reportable in limited circumstances.

Billing Rule

Incision and drainage billing

Incision and drainage performed as part of another procedure or to gain access is not separately reportable when performed at the same anatomic site and encounter; I&D codes should not be reported separately with procedures at the same site.

Billing Rule

Lesion removal and pathology reporting

Only one lesion removal code may be reported per lesion/procedure; skin biopsy codes (11102-11107) and pathology for the same lesion are included and are not separately reportable unless the biopsy is of a different lesion or staged/planned per modifier guidance.

Billing Rule

Mohs surgery coding

Mohs micrographic surgery CPT codes include biopsy and pathology services; do not report those additional biopsy or pathology codes when reporting Mohs, except a diagnostic biopsy performed prior to Mohs may be reported separately with appropriate modifiers (e.g., 59, XS, XU, or 58) to indicate staged/planned or distinct service.

Billing Rule

Intralesional injections

Do not report multiple intralesional injection codes together unless different agents are injected into separate lesions; reporting these codes for administration of local anesthesia for another procedure is misuse.

Billing Rule

Repair, tissue transfer, grafts/flaps billing

Adjacent tissue transfer (CPT 14000-14350) includes excision and repair; graft and skin substitute primary codes are mutually exclusive and use AOCs for larger sizes; debridement related to grafts/transfers is included and not separately reportable.

Billing Rule

Breast procedures coding

Mastectomy procedures include removal of lesions within breast tissue; excision codes are not separately reportable unless unrelated or staged (modifier 58); sentinel lymph node biopsy is separately reportable when performed before localized excision or mastectomy without lymphadenectomy.

Note

MUE guidance

Follow MUE unit-of-service rules: fine needle aspiration units are per distinct lesion, Mohs IHC (88342) one unit per specimen with additional stains (88341) reported per additional stain, and bilateral procedures must follow modifier 50 and single-line unit reporting rules unless code descriptor defines 'bilateral' or ASC reporting rules apply.

Billing Rule

General billing and policy statements

NCCI PTP edits and MUEs apply to services furnished by the same physician (as broadly defined) to the same beneficiary on the same date of service; providers must not alter dates of service to avoid edits.

Billing Rule

E&M reporting modifiers in global periods

When an E&M is separately reportable on the same date as a procedure, append modifier 57 for preoperative E&M that represents the decision to perform major surgery, modifier 25 for a significant, separately identifiable E&M with minor or certain XXX procedures, and modifier 24 for unrelated postoperative E&M during the global period.

Billing Rule

Anesthesia reporting limitations

Anesthesia CPT codes (00100-01999, 62320-62327, 64400-64530) are not separately reportable by the physician performing the procedure; moderate conscious sedation codes (99151-99153) may be reportable separately except when specifically bundled.

Documentation Required

MUE modifier caution

Avoid frequent use of modifiers solely to bypass MUEs; repeated modifier workarounds may indicate incorrect UOS reporting and providers should consult local contractors or national specialty organizations if uncertain.

Documentation Required

E&M modifier guidance for global periods

When E&M services are separately reportable on the same date as a procedure, append modifier 57 for decision-for-surgery E&M for major procedures, modifier 25 for significant separately identifiable E&M with minor procedures, and modifier 24 for unrelated postoperative E&M.

Billing Rule

Use of NCCI PTP-associated modifiers

NCCI PTP-associated modifiers (e.g., 59, XU, XE, XS, XP) may be used to report contralateral or distinct-site services when the modifier criteria and CCMI allow bypassing the edit; documentation must support the use.

Billing Rule

Endoscopy separate reporting guidance

Do not separately report a diagnostic endoscopy when it is performed solely to evaluate the surgical field or confirm adequacy of a concurrent open surgical procedure; diagnostic endoscopy may be separately reported only when its findings lead to a separate nonendoscopic surgical decision.

Billing Rule

Conversion from endoscopic to open procedures

When a surgical endoscopy is converted to an open procedure at the same encounter, neither the diagnostic nor surgical endoscopy codes are separately reportable with the open procedure; use modifier 58 when the endoscopic procedure was staged/planned and documentation supports it.

Billing Rule

Intraoperative imaging reporting limits

CPT 76998 (intraoperative ultrasound guidance) may be reported with certain CABG epi-aortic ultrasound only when appended with modifier 59 or XS; ultrasound used to procure vascular grafts or solely to guide graft procurement is not separately reportable.

Billing Rule

Repeat angiography reporting rules

A repeat diagnostic angiogram performed on the same date as an interventional procedure is reportable only if medically necessary; when reportable use modifier 59 or XU (and modifier 52 if only a partial repeat study was performed).

Documentation Required

E&M modifier guidance

When E&M services on the same date are separately reportable per global surgery rules, append appropriate modifiers (e.g., 57, 25, 24); be aware MACs may implement separate edits and instructions.

Billing Rule

Endoscopy modifier guidance

When multiple endoscopic procedures are reported at the same encounter, append modifier 51 to secondary codes; use modifier 78 for repeat endoscopy requiring return to the OR/endoscopy suite on the same date.

Billing Rule

Abdominal procedure reporting and modifier 22

Do not separately report exploratory or component procedures that are integral to larger abdominal or transplant procedures; if extensive/time-consuming enterolysis is performed, the provider may append modifier 22 to seek additional payment and the local MAC will determine payment.

Billing Rule

Enterolysis modifier 22 guidance

If extensive or time-consuming enterolysis is performed with another intra-abdominal/pelvic procedure, the provider may append modifier 22 to the other procedure code; the local MAC determines whether additional payment is appropriate.

Documentation Required

MUE avoidance advisory

Providers should not frequently use modifiers or claim-line workarounds to bypass MUEs; frequent use may indicate incorrect UOS reporting and providers should consult national specialty organizations or local contractors if unsure.

ImplementationApplied to claims submitted to MACs, DME MACs, and outpatient facility claims; adjudicated as claim-line or DOS edits depending on MAI.

RoleMUEs are coding/unit edits and do not replace medical necessity or other coverage determinations.

inv-105: AOC — Add-on Code edits definition

DefinitionAdd-on Code (AOC): a HCPCS/CPT code that describes a service reportable only in addition to a primary procedure; rarely eligible for payment when billed alone.

Types and MAC rolesCMS publishes AOC-to-primary mappings annually and updates quarterly; Type 1 AOCs have defined primary codes and MACs must follow them; Type 2/3 allow MAC discretion within guidance.

Relation to NCCI PTPNCCI PTP edits generally do not include most AOCs because primary-code edits prevent inappropriate payment, but some AOC edits exist when supplementary restrictions are needed.

inv-106: HCPCS/CPT — coding systems referenced

Coding systemsHCPCS Level I (CPT) and Level II codes are used to report medical and surgical services to Medicare; CPT codes are defined by the AMA CPT Professional codebook and HCPCS Level II by CMS.

UpdatesCPT is updated annually by the AMA; HCPCS Level II is updated throughout the year by CMS as needed.

Use in NCCINCCI policies and edits are based on HCPCS/CPT descriptors, CPT guidelines, CMS instructions, and standards of medical/surgical practice.

inv-107: MUE — restated definition

Restated MUE definitionMUE: the maximum units of service for a HCPCS/CPT code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.

ObjectiveLower the Medicare paid claims error rate by limiting unlikely unit counts on a single DOS.

ApplicationUsed as claim-line or DOS edits; MUE files include MAI and Edit Rationale for each code.

inv-108: PTP edit — definition of a Procedure-to-Procedure edit

PTP edit definitionA Procedure-to-Procedure (PTP) edit pairs two HCPCS/CPT codes (Column One/Column Two) that generally should not be reported together at the same encounter; Column One is paid and Column Two denied unless an allowed modifier justifies payment for both.

Misuse contextSome PTP edits represent misuse of Column Two codes reported in inappropriate contexts; limited circumstances may allow reporting with a third code or with appropriate modifiers.

Modifier roleNCCI PTP-associated modifiers (when allowed) permit payment of both codes when clinical criteria (separate site/encounter) are met.

inv-109: Component services — definition and examples

Component servicesComponent services are tasks that are standard-of-care components of comprehensive procedures (e.g., skin prep, draping, IV access, anesthesia, imaging, wound irrigation, surgical closure) and generally are included in payment for the comprehensive procedure.

PrinciplesComponent services are usually necessary to complete the comprehensive service and are not separately distinguishable when performed with the comprehensive service.

ExamplesExamples listed include insertion/removal of drains, wound irrigation, imaging guidance, and application of postoperative dressings/supplies.

inv-110: Modifier 59 — definition and intended use

Modifier 59 definitionModifier 59 (Distinct Procedural Service) indicates a procedure/service distinct or independent from other services on the same day when documentation supports a different session, site, lesion, or separate encounter; use more specific modifiers if available.

Appropriate useUse only when no more specific modifier applies; documentation must support separate session/site/lesion/encounter; not intended to bypass PTP edits absent criteria.

Related modifiersXE (Separate Encounter), XS (Separate Structure), XP (Separate Practitioner), XU (Unusual Non-overlapping Service) were created to provide greater specificity and may be used in lieu of 59.

inv-111: Global surgery period — description of global period indicators

Global period indicatorsGlobal periods: 000, 010, 090, XXX, YYY, ZZZ, MMM — determine whether E&M services on same day are included in procedure payment or may be separately reportable (e.g., modifier 57 for decision to perform major surgery (090)).

Major vs minor090 = major surgical procedure (preoperative decision E&M may be billed with modifier 57); 000/010 = minor (significant separate E&M may be billed with modifier 25).

XXX/YYY/ZZZ specificsXXX procedures are not governed by global rules; YYY is defined by MAC; ZZZ relates to another procedure and uses related procedure's global period.

inv-112: XE — Separate Encounter definition

XE definitionXE — Separate Encounter: a service distinct because it occurred during a separate encounter on the same date of service.

Usage noteUse XE to indicate same-date separate encounters; documentation must support separate encounter timing.

inv-113: XS — Separate Structure definition

XS definitionXS — Separate Structure: a service distinct because it was performed on a separate organ/structure (different anatomic site).

Appropriate contextUse XS when procedures are on distinct organs/structures that are not contiguous and documentation supports separate structure.

inv-114: XP — Separate Practitioner definition

XP definitionXP — Separate Practitioner: a service distinct because it was performed by a different practitioner.

Use caseAppropriate when a second practitioner performs a distinct service (e.g., intraoperative neurophysiology by a non-operating physician) and documentation reflects distinct practitioner involvement.

inv-115: XU — Unusual Non-Overlapping Service definition

XU definitionXU — Unusual Non-Overlapping Service: service distinct because it does not overlap usual components of the main service.

When to useUse XU when the service is unrelated to and does not overlap the usual components of the primary service, with documentation to support the distinction.

inv-116: CPT 'Separate Procedure' designation

MeaningCPT 'Separate Procedure' designation: a code descriptor including 'separate procedure' generally means the code is not separately reportable when performed in an anatomically related region through the same approach; it is subject to NCCI PTP edits.

ExceptionsMay be reported if performed at a separate encounter on same date or at an anatomically unrelated area; modifiers 59/XE/XS may be appended when criteria met.

CMS interpretationCMS interprets 'separate procedure' designation to prohibit separate reporting with anatomically related procedures at the same encounter unless separate site/encounter evidence is documented.

inv-117: Misuse of Column Two code — description

Misuse describedMisuse of Column Two code occurs when a code is reported in contexts different from its intended use (e.g., reporting operating microscope 69990 with procedures not listed as allowable); NCCI edits restrict such misuse and may allow limited exceptions.

ExamplesSome Column Two codes may be appropriate with a third code or in limited circumstances; careful review of code descriptors and NCCI guidance is required.

inv-118: Mutually exclusive — definition for procedures that cannot be performed together

DefinitionMutually exclusive procedures: code pairs that cannot reasonably be performed together at the same anatomic site or encounter; included in NCCI PTP tables to prevent reporting incompatible methods or duplicate initial/subsequent services.

Modifier allowanceMany mutually exclusive edits allow NCCI PTP-associated modifiers if procedures are performed on different anatomic sites or separate encounters.

inv-119: Add-on Code — definition and constraints

Add-on Code (AOC)An AOC describes a service reportable only in addition to a primary procedure; AOCs rarely paid when billed alone and CMS publishes mappings and guidance (Type 1/2/3) for MAC implementation.

ConstraintAOCs must be billed only with allowed primary codes per CPT or CMS guidance; MACs enforce Type 1 lists and manage Type 2/3 with discretion per instructions.

inv-120: MUE — concise MUE definition

Concise MUE definitionMUE: edit values limiting units of service for a HCPCS/CPT code per date of service for the same provider and beneficiary to prevent incorrect multiple reporting.

Primary goalReduce Medicare paid claims errors by flagging unlikely unit quantities on a single DOS.

Files and visibilityMUE files include MAI and Edit Rationale and are published on the CMS NCCI MUE webpage.

inv-121: MAI — MUE Adjudication Indicator meanings

MAI indicatorsMAI on MUE files: '1' = claim-line MUE; '2' or '3' = DOS MUE classifications where '2' indicates absolute DOS edits and '3' indicates DOS edits based on clinical benchmarks.

Operational effectMAI determines whether modifiers and per-line reporting can affect adjudication (MAI=1) or whether summed DOS limits apply (MAI=2/3).

inv-122: MUE — determination inputs emphasizing prescribing info and clinical assumptions

DeterminantsMUEs are based on prescribing information, claims data, clinical dosing assumptions (weight/BSA), patient response, and published use; some non-drug codes use other rationales (e.g., procedure inpatient-only status) and some MUEs set to 0 for specific reasons.

Claims-data roleWhen 'Data' is the Edit Rationale, 100% claims data from a six‑month period often was the primary factor in setting the MUE value.

Appeals focusAppeals reviewers for 'Data'-based MUEs will verify correct code, correct UOS counting, and medical reasonableness when evaluating denials.

inv-123: Add-on Code (AOC) — definition emphasizing primary code requirement

AOC definitionAdd-on Code: a CPT/HCPCS code describing a service typically performed in conjunction with a primary code and reportable only as an add-on; CMS publishes AOC-primary mappings annually with quarterly updates.

Primary code requirementAn AOC is reportable only when an appropriate primary procedure is also reported as defined by CPT or CMS Type 1/2/3 guidance; AOC alone is rarely payable.

inv-124: Anesthesia time — definition of continuous anesthesia time

Anesthesia time definitionAnesthesia time: the continuous period during which an anesthesia practitioner is present with the patient, beginning when preparation for anesthesia begins and ending when the practitioner no longer furnishes anesthesia services; anesthesia time is continuous though blocks around interruptions may be added if continuous care is furnished.

Implication for unitsAnesthesia payment is based on base units plus time units; time reporting conventions affect unit calculations for timed services and related MUE considerations.

inv-125: Global period — definitions and examples

Global period indicators explainedGlobal period indicators: 000, 010, 090, XXX, YYY, ZZZ, MMM — define time windows for included pre-, intra-, and postoperative services; 090 = major, 000/010 = minor, XXX = not governed by global rules, MMM = maternity; YYY/ZZZ defined by MAC or relation to another procedure.

E&M reporting impactThese indicators determine when E&M services on the same day may be separately reportable with modifiers 57 (decision-for-surgery major) or 25 (significant separately identifiable E&M for minor/XXX), or 24 (unrelated postoperative E&M).

MAC roleMACs may have separate edits implementing global rules; NCCI applies to same-provider same-beneficiary same-date contexts but does not duplicate all MAC edits.

inv-126: Modifier 25 — definition and intended use

Modifier 25Modifier 25: appended to an E&M code to indicate a significant, separately identifiable E&M service on the same day as a minor procedure (global 000/010) or some XXX procedures.

Appropriate useUse only when E&M service is above and beyond the usual pre-/post-procedure work and documentation supports the separate, significant service.

Not for decision-for-surgeryDo not use 25 for preoperative decision-for-surgery when modifier 57 is appropriate for major procedures (090).

inv-127: Modifier 57 — definition and intended use

Modifier 57Modifier 57: appended to an E&M when it represents the decision to perform major surgery on the same date as the procedure (global 090), allowing separate reporting for that decision E&M.

ScopeApplies to decision-for-surgery E&M on same date as major procedures; other preoperative E&M on same date are included in global payment.

DocumentationDocumentation should support that the E&M resulted in the decision to proceed with major surgery.

inv-128: Medically Unlikely Edit — emphasis on preventing overbilling

MUE purposeMUEs are CMS-established limits on units of service per beneficiary per date of service intended to prevent overbilling and incorrect multiple reporting.

ApplicationMUEs apply across providers/suppliers for the same beneficiary on the same date; adjudicated as claim-line or DOS edits depending on MAI.

Not usage guidanceAn MUE is a coding/unit edit and not a utilization or medical necessity guideline; separate medical necessity review may still apply.

inv-129: Physician — definition as used in manual

'Physician' term scopeIn this manual, the term 'physician' generally refers to physicians and other practitioners, hospitals, providers, or suppliers eligible to bill the relevant HCPCS/CPT codes unless sections explicitly limit the term.

Applicability noteSome specific rules (e.g., anesthesia rules, global surgery) may not apply to hospitals or certain provider types; consult section-specific guidance.

inv-130: Global period — additional reference

Global period restatementGlobal period indicators (000,010,090,XXX,YYY,ZZZ,MMM) determine whether pre/intra/postoperative services are included in procedure payment and whether E&M on same day may be separately reportable (e.g., 57,25,24).

MAC-defined categoriesYYY is defined by the MAC; ZZZ relates to another procedure and uses that procedure’s global period.

Practical effectGlobal period rules interact with NCCI PTP edits because edits apply to same-provider same-beneficiary same-date services; MACs may maintain separate edits for E&M handling.

inv-131: Separate procedure (CMS policy)

Separate procedure definition (CMS)CMS: a CPT code designated 'separate procedure' may not be separately reported with a related procedure performed in an anatomically related area through the same incision/orifice/approach at the same encounter; it is subject to NCCI PTP edits.

When permissibleMay be reported if performed at separate patient encounter on same date or at an anatomically unrelated area; use modifiers (59/XE/XS) when criteria documented.

inv-132: Add-on Code (AOC) for vertebral levels

AOC for vertebral levelsWithin spine code families, Add-on Codes (AOCs) report the same procedure at each additional contiguous vertebral level; one primary code for first level and AOC(s) for additional levels.

Contiguous vs noncontiguousFor contiguous levels through same incision report primary + AOC(s); for noncontiguous levels through separate incisions, report primary codes per region as allowed.

Example familiesCPT families (e.g., 22532-22534; 22510-22515; 22600 series) use primary/AOC structure to report levels per CMS guidance.

inv-133: MUE — restated definition

MUE restatementMUE: edit values limiting units of service per date of service to prevent incorrect multiple reporting; applied as claim-line or DOS edits per MAI.

Files include MAIMUE files on CMS website include an MUE Adjudication Indicator and an Edit Rationale for each code to explain basis of value.

AppealsDenials due to MUEs may be appealed to local contractors; contractors may apply more restrictive edits than published MUEs.

inv-134: Policy-to-Policy (PTP) edit — definition of PTP edit pairing

PTP pairingPolicy-to-Policy (PTP) edit: pairs two CPT codes to indicate they represent different surgeries/procedures and generally should not be reported together at the same anatomic site on the same encounter; Column One paid, Column Two denied unless appropriate modifier used.

Clinical rationalePTP edits capture situations where code descriptors represent distinct surgeries or where combined reporting would be clinically inappropriate or redundant.

Modifier interactionNCCI PTP-associated modifiers may permit payment of both codes when clinical criteria (separate site/encounter) are documented and CCMI allows.

inv-135: Global period — duplicate/global period reference

Global period indicatorsGlobal periods (000,010,090,XXX,YYY,ZZZ,MMM) assign bundled pre/intra/postoperative services and affect separate E&M reporting; major/minor/XXX distinctions determine modifier use.

E&M modifiersModifier 57 used for decision-for-surgery E&M with major (090); modifier 25 for significant separate E&M with minor (000/010) or certain XXX; modifier 24 for unrelated postoperative E&M.

inv-136: NCCI PTP-associated modifier — definition

PTP-associated modifiersNCCI PTP-associated modifiers (e.g., 59, XE, XS, XP, XU) may allow two codes to be reported when procedures are on contralateral or separate anatomic sites or separate encounters; CCMI '1' typically indicates modifiers may be used.

CautionModifiers should not be appended solely to bypass edits; documentation must support criteria and MACs may limit modifier use for some codes.

Bilateral contextMany bilateral code edits have CCMI '1' because contralateral reporting may be appropriate; ipsilateral contiguous procedures generally should not use modifiers to bypass edits.

inv-137: Diagnostic vs surgical endoscopy — definition and reporting differentiation

Diagnostic vs surgical endoscopyDiagnostic endoscopy is not separately reportable with surgical endoscopy; diagnostic endoscopy may be separately reportable only when its findings lead to a separate nonendoscopic surgical decision or when performed at a separate encounter.

Conversion ruleIf an endoscopy is converted to an open procedure, endoscopic codes (diagnostic or surgical) are not separately reportable with the open procedure unless staged/planned circumstances with appropriate modifier (e.g., 58) exist.

Intraoperative evaluationEndoscopy performed solely to evaluate the surgical field or confirm adequacy is not separately reportable with the open procedure.

inv-138: Separate procedure (CMS policy) — definition

CMS separate procedure policyCMS policy: a CPT code designated 'separate procedure' is generally not separately reportable with an anatomically related procedure at the same encounter; may be reported when performed at separate encounter or unrelated area with proper modifiers.

ExamplesTracheostomy (31600) labeled 'separate procedure' is not separately reportable with related laryngeal procedures; laryngoscopy for tracheostomy placement is not separately reportable.

Modifier guidanceModifiers 59/XE/XS may be appended when criteria for separate encounter/site/practitioner are met and documented.

inv-139: Mechanical thrombectomy primary vs secondary — definition and bundling note

Mechanical thrombectomy bundlingCPT instructions define primary vs secondary percutaneous transluminal mechanical thrombectomies; primary mechanical thrombectomy (e.g., 37184) is bundled into many percutaneous arterial interventional procedures and NCCI edits reflect this bundling.

Modifier allowanceEdits allow use of NCCI PTP-associated modifiers if a provider performs a primary thrombectomy rather than a secondary thrombectomy in conjunction with another percutaneous arterial procedure, when clinically appropriate.

Atherectomy implicationThrombectomy of thrombus in the vascular territory of a diseased artery is inherent in atherectomy work and secondary thrombectomy codes (e.g., 37186) shall not be reported for such removal.

inv-140: Correct coding principle — report greatest specificity

Correct coding principleReport the HCPCS/CPT code that describes the procedure performed to the greatest specificity possible; do not unbundle when a single code exists to describe the services performed.

Do not fragmentProviders shall not fragment a procedure into component parts or report multiple codes when one comprehensive code exists.

Standards of practice basisNCCI policies are grounded in CPT descriptors, CMS instructions, national coding guidance, and standards of medical/surgical practice.

inv-141: Global surgery periods — determination of E&M reporting rules during global periods

'Physician' usageIn this manual, 'physician' generally refers to any practitioner, hospital, provider, or supplier eligible to bill the relevant HCPCS/CPT codes unless specific rules exclude certain entities.

ImplicationMany NCCI rules apply broadly beyond individual physicians to all eligible billers unless a section explicitly limits applicability.