When to Use Modifiers to Bypass Correct Coding Edits

Q. How do you know when it's OK to use an appropriate modifier to bypass a Medicare National Correct Coding Initiative (NCCI) edit?

A. You may append modifiers to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier, such as for services provided to different anatomic sites. The Novitas Medicare Reference Manual lists HCPCS modifiers that may cause bypass of CCI editing for a reported code pair. But remember, the patient's medical record must reflect that the modifier appropriately describes separate services.

Do not append a modifier to an HCPCS/CPT code solely to bypass an NCCI edit if the clinical circumstances do not justify its use.

The Centers for Medicare & Medicaid Services maintains the NCCI code pair table lookups. Within the table, the "modifier indicator column" displays whether an NCCI-associated modifier allows the code pair to bypass the edit. The modifier indicators are:

 Not Allowed. No modifiers associated with NCCI are allowed with this code pair; there are no circumstances in which both procedures of the code pair should be paid for the same beneficiary on the same day by the same provider.

 Allowed. The modifiers associated with NCCI are allowed with this code pair when appropriate.

 Not Applicable. An NCCI edit does not apply to this code pair. The edit for this code pair was deleted retroactively.

For more information on how to use the edits, refer to the CMS guide, How to Use the National Correct Coding Initiative (NCCI) Tools (PDF), and CMS white paper, "Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service" (PDF).

Published May 27, 2014

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Last Updated On

June 03, 2016

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