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MEGA - NCCI Edit Changes - WHO Knew?

Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

There was no huge announcement when CMS released new files in April. The files that were released on April 7, 2020 actually replaced files to update the NCCI edits on Procedure to Procedure (PTP) edits and Medically Unlikely Edits (MUE). The updated files included:

  • 291,902 Deleted Procedure to Procedure (PTP) edits
  • 197  Deleted Medically Unlikely edits (MUE)

This was no small change. The deleted PTP pairs include anesthesia services and procedures as well as E/M visits. We have included a spreadsheet for your reference which can be reviewed here: CMS April 01, 2020 Revisions.  

Edits Removed from CCI editor with E/M and Modifier 25

One significant change in the 291,902 Procedure to Procedure (PTP) edits was the removal of the edits with E/M codes. Prior to this change, we would see an ERROR or a WARNING looking for a CCI-associated modifier such as a 25, but those edits have been removed. 

Change your viewing date to see the edits prior to the new changes

(Some edits are effective Jan 01, 2020, and some are effective April 01, 2020) 

Removing the edits on the E/M codes will now allow the use of the new or existing telemedicine service codes. Telemedicine codes are identified with a STAR ICON on the code information page, indicating they can be used as a telemedicine service as well as face-to-face.     

Prior to April 01, 2020:

99201 - NCCI Edit Results: ERROR- Edit exists with 00100. 99201 is a Column 2 code. If both 00100 and 99201 are submitted, only 00100 will be paid.

This edit CANNOT be overridden via CCI-associated modifiers.
Rationale: Standard preparation/monitoring services for anesthesia

00100- OK- NCCI Edit Results: No NCCI Edits for this code.

After April 01, 2020:

99201 OK- NCCI Edit Results: No NCCI Edits for this code.
00100 OK- NCCI Edit Results: No NCCI Edits for this code.

Keep an eye on the MUEs, as the frequency limits have been eliminated for the use of telehealth and other communication-based services; this involves 199 codes. We are not sure if this is temporary or a permanent change.   

It is important to note that if there is not a CCI edit or a warning, you are still required to follow standard coding guidelines and rules. If there is an NCCI policy or rule, refer to the current NCCI Policy Manual for Medicare Services. The policy manual addresses all of the CCI policies and can be found on the NCCI Page in Find-A-Code at the top of the page, which makes it easily accessible.    

See the NCCI Policy Manual: Chapter I Section D, Evaluation and Management (E&M) Services for the use of Modifier 25.

For additional information on using Modifier 25 with E&M codes, refer to this article: "Where is the CCI Edit with Modifier 25 on E/M?"

Important NOTE: The NCCI edit manual is updated yearly in October, however, there may be quarterly changes that are not showing on the current manual. For updated quarterly Replacement, Additions, Deletions, and revisions visit CMS Quarterly PTP and MUE Version Update Changes.