This is a reminder that as of January 1, 2015, the Centers for Medicare &
Medicaid Services (CMS) National Correct Coding Initiative (NCCI) edits are
applicable to claims submitted on the CMS-1500 claim form or through the 837P
transaction. Please refer to our Commercial and Medicare Advantage claim
payment policies on NCCI edits, which are available on our Medical Policy Portal. Select Accept and Go to Medical
Policy Online, and then select the Commercial or Medicare
Advantage tab from the top of the page, depending on the version of the
policy you?d like to view:
- Commercial: #00.01.56a: National Correct Coding Initiative
(NCCI) Code Pair Edits;
- Medicare Advantage: #MA00.041: National Correct Coding
Initiative (NCCI) Code Pair Edits.
The CMS NCCI tables (Column 1/Column 2) are composed of code pair edits.
These code pair edits identify services that are a component of a more
comprehensive code or two codes that should not be reported together. Procedure
code pairs designated by CMS with an NCCI modifier indicator of 0 (zero) are
not eligible to be reimbursed separately when reported on the same date of
service for the same member when performed by the same provider. The NCCI edit
identified in the CMS NCCI file for these procedure code pairs will be applied
by Independence regardless of the presence of a modifier.
Modifiers 25 and 59
Procedure code pairs designated by CMS with an NCCI modifier indicator of 1,
when clinically appropriate, are eligible to be reported with an appropriate
modifier for separate reimbursement. The most frequently used modifiers are 25
and 59.
- Modifier 25: Modifier 25 is required when a significant,
separately identifiable Evaluation and Management (E&M) service is performed by
the same physician on the same day of a procedure or other service. For
example, if an E&M service was also performed on the same day as an
administration of an immunization, the E&M service should be billed with the
modifier 25.
- Modifier 59: Modifier 59 is required to indicate that a
procedure or service is separate, distinct, or independent from other non-E&M
services performed on the same day by the same individual.
For more information
For more detailed information regarding the appropriate use of these
modifiers, please visit our Medical Policy Portal. Select
Accept and Go to Medical Policy Online, and then select the
Commercial or Medicare Advantage tab from the top of the
page, depending on the version of the policy you?d like to view:
- Modifier 25:
- Commercial: #03.00.06l: Modifier 25: Significant,
Separately Identifiable Evaluation and Management Service by the Same Physician
on the Day of a Procedure or Other Service;
- Medicare Advantage: #MA03.003a: Modifier 25: Significant,
Separately Identifiable Evaluation and Management Service by the Same Physician
on the Day of a Procedure or Other Service.
- Modifier 59:
- Commercial: #03.00.08c: Modifier 59: Distinct Procedural
Service;
- Medicare Advantage: #MA03.005: Modifier 59: Distinct
Procedural Service.
Please refer to the CMS NCCI file for procedure
code pair edits and the associated modifier indicators.