CurrentOptumPolicy N/A

NCCI edits and modifier use for behavioral health reimbursement

Governance of reimbursement for CPT/HCPCS coding interactions (NCCI/PTP edits and designated modifiers) for services billed to Optum behavioral health plans; applies to providers submitting CMS 1500/837p (and when specified UB-04/837i) for Medicare, commercial, Individual Exchange, and Medicaid products.

Policy Summary

PayerOptum

PolicyNCCI edits and modifier use for behavioral health reimbursement

Policy CodePolicy N/A

Change TypeClarified (Q&A additions)

Effective DateN/A

Next Review DateN/A

Key ActionDo not report column two codes separately unless an accepted NCCI modifier (25,59,XE,XP,XU) is appended and the modifier indicator allows bypass of the edit.

SourceLink

POLICY UPDATE CHANGES

December, 2020 — Added Q&A 3 related to 96127.

January, 2025 — Added Q&A 1 related to CPT code 90791 & 90792.

5designated modifiers recognized (25, 59, XE, XP, XU)

90791/90792evaluation codes limited for repeat billing

96127code not reimbursed with therapy session

CMS NCCI & Medicaid PTPedits applied

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Separate Reimbursement Criteria

Separate reimbursement criteria

Covered for separate reimbursement when ALL of the following apply:

Apply NCCI/PTP edits: Codes are billed by the Same Individual Physician or Other Health Care Professional for the same member on the same date of service; Optum administers CMS NCCI (Column One/Column Two) and Medicaid PTP edits to determine separate reimbursement eligibility.

Modifier indicator and modifier requirement: A column two (or PTP column two) code will not be separately reimbursed unless the NCCI modifier indicator for the edit = '1' and an accepted NCCI-designated modifier is appended to the appropriate code.

Accepted modifiers: The appended modifier must be one of the NCCI-designated modifiers recognized by Optum: 25, 59, XE, XP, or XU; when appended and the modifier indicator = '1', Optum will consider both services for reimbursement.

Documentation and medical records: When exceptions are claimed (for example repeat 90791/90792), medical records may be required to support separate reimbursement determination.

Behavioral health code-specific rules

90791 or 90792: Optum will not reimburse additional units for the same member and same provider on the same or different dates of service except in limited circumstances (extended break in treatment, inpatient admission for psychiatric illness, or significant change in mental status requiring further assessment).
96127: Not reimbursed when billed as part of any therapy session (e.g., cannot bill 96127 with 90791).

Incidental / mutually exclusive / transferred / unbundled services: Services determined to be incidental, mutually exclusive, transferred, or unbundled to a more comprehensive service are not separately reimbursed unless reported with an appropriate NCCI-designated modifier and the edit's modifier indicator permits bypassing the edit.

Modifier indicator interpretation: An assigned modifier indicator of '0' means a modifier cannot bypass the edit; an indicator of '1' means an NCCI-designated modifier (25,59,XE,XP,XU) may allow both services to be considered for reimbursement when properly appended and documented.

NCCI Modifiers and Code-specific Notes

Designated NCCI modifiers recognized by OptumModifierCovered

25	Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
59	Distinct Procedural Code
XE	Separate encounter
XP	Separate practitioner
XU	Unusual non-overlapping service

Behavioral health code-specific reimbursement notesCPT

90791/90792	Psychiatric diagnostic evaluation / with medical services — Optum will not reimburse additional units for same provider/member on same or different dates except in limited circumstances (extended break in treatment, inpatient admission for psychiatric illness, or significant change in mental status); medical records may be required
96127	Brief emotional/behavioral assessment — not reimbursed when billed as part of any therapy session

inv-04: NCCI modifier indicator requirement — Column two codes not reimbursed unless NCCI modifier indicator = '1' and an accepted modifier is appended

RequirementColumn two (PTP column two) codes will not be separately reimbursed when reported with a column one code unless an NCCI modifier indicator = '1' and an accepted NCCI modifier is appended.

When modifier appliesIf one of the designated modifiers (25, 59, XE, XP, XU) is appended to either the column one or column two code for the same patient, same date of service, and Same Individual Physician/Other Health Care Professional, Optum will consider both services for reimbursement when the modifier indicator = '1'.

ScopeApplies to CMS NCCI (Column One/Column Two) edits and Medicaid PTP edits as administered by Optum for behavioral health reimbursement.

Billing Guidance and Modifier Use

Billing Rule

Modifier use and NCCI edits — append accepted modifier or expect denial

Do not report column two codes separately when they are incidental, mutually exclusive, transferred, or unbundled to a more comprehensive service unless an appropriate NCCI modifier is appended; Optum follows NCCI/PTP edits and will only consider both services for reimbursement when an accepted modifier (25, 59, XE, XP, XU) is appended and the NCCI modifier indicator = '1'.

Optum will not reimburse services determined to be Incidental, Mutually Exclusive, Transferred, or Unbundled unless reported with an appropriate modifier. [[chunk 4]]
When reported with a column one code, Optum will not separately reimburse a column two code unless an accepted NCCI modifier (25, 59, XE, XP, XU) is appended and the NCCI modifier indicator = '1'. [[chunk 5]]

Key Definitions

inv-06: The same individual rendering health care services reporting the same Federal Tax Identification number — Same Individual Physician or Other Health Care Professional

DefinitionSame Individual Physician or Other Health Care Professional = The same individual rendering health care services reporting the same Federal Tax Identification number.

ApplicationUsed to determine eligibility for separate reimbursement when multiple CPT/HCPCS codes are billed to the same member on the same date of service under NCCI/PTP edits.

Relevant programsApplies across Medicare NCCI (national) and Medicaid PTP (state-level) edits as implemented by Optum.

inv-07: Modifier indicator (NCCI) — '0' indicates modifier cannot bypass edit; '1' indicates modifier can allow both services

Indicator = 0An assigned modifier indicator of '0' means a modifier cannot be used to bypass the NCCI edit.