Q: Can I override Medicare’s NCCI edits?
A: Yes. The Medicare National Correct Coding Initiative (NCCI) uses automated edits to identify pairs of services that normally a physician should not bill for the same patient on the same day.
NCCI code pairs are assigned a status, identified as a code pair superscript. This can be 0, 1, or 9: “0” means a modifier is not allowed and will not override an edit; “1” means a modifier is allowed, when appropriate, for two services or procedures performed at separate sessions or separate sites during the same session; and “9” means the edit is no longer applicable.
NCCI allows the following modifiers:
- Anatomical modifiers: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9;
- Global surgery modifiers: 25, 58, 78, 79; and
- Others: 59, 91.
Some modifiers frequently are misused. Follow these guidelines for modifiers 25, 59, and 91.
- Modifier 25 — Append modifier 25 to an evaluation and management (E&M) code when reporting it with another procedure on the same day of service. This indicates that as a result of the patient’s condition, the physician performed a significant, separately identifiable E&M service above and beyond the other service provided.
- Modifier 59 — Use modifier 59 to indicate a procedural service distinct from others billed on the same date of service. This may represent a different session, different anatomical site or organ system, separate incision/excision, different lesion, or different injury or area of injury (in extensive injuries). When used with a CCI edit, modifier 59 indicates that the procedures are different surgeries when performed at different operative areas or at different patient encounters.
- Modifier 91 — Append modifier 91 to laboratory procedure(s) or service(s) to indicate a repeat test or procedure on the same day. This modifier indicates that the physician had to perform a repeat clinical diagnostic laboratory test that was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain medically necessary subsequent reportable test values. Do not use this modifier to report repeat laboratory testing due to laboratory errors, quality control, or confirmation of results.