National Correct Coding Initiative (NCCI)

It has been a flip-flop kind of year for the Center for Medicare & Medicaid Services (CMS) when it comes to deciding which CPT codes can and can’t be billed together. These code combinations or “edits” are near and dear to therapy professionals, put in place to control improper coding which can lead to inappropriate Medicare Part B billing. CMS owns the NCCI program and makes all edit decisions, and 2020 was the year for indecisiveness! Edit changes are released quarterly, with changes impacting “therapy-used” codes seen infrequently, though CMS just made a 3rd change for 2020!

Flip-Flop #1

Back in January therapists discovered CMS unexpectedly added edits to the list that we have gotten very comfortable with. Just like that, PT/OT Evaluations (97161, 97162, 97163, 97165, 97166, 97167) and Therapeutic Activities (97530) could not be billed together on the same day, for the same patient, across all disciplines with the same provider. [Think SNF]  If billed together, clinicians would not be paid for the evaluation.

For example, if PT was billing an evaluation on the same day OT was billing Therapeutic Activities, the PT Evaluation would not be paid. With certain code combinations, Modifier 59 can often be used to bypass the edit showing that the services were provided separately. However, CMS was not granting this option. The same scenario was in play for Group Therapy (97150) and therapy evaluations.

Additional changes including adding the need for the 59 Modifier for several code combinations, such as:

  • Therapeutic Activity and Gait Training
  • Group and Therapeutic Exercise
  • Evaluations and Manual Therapy
  • Reevaluations and multiple codes

Flip-Flop #2

A few months later, CMS decided to remove the new edits and go back to the edits from pre-January 2020. No reason was given, though likely in part related to COVID-19 & the Public Health Emergency,  and strong advocacy from APTA / AOTA / ASHA.

Flip-Flop #3

In late summer, CMS announced that they were, once again, going to make changes and effective October 1st, 2020, reinstate the edits that they removed in April. Confused yet? Yikes!

Our professional associations continued to advocate for holding off on this change for 10/1/20.

Where Do We Stand Now?

Well, CMS released the 10/1/2020 NCCI edit files….and things do not look too terrible. Most code combinations allow for a 59 Modifier if appropriate, and the list is nothing like the January 1st changes…but 2020 isn’t over yet!

There are some differences between the code combinations the “practitioners” can use [referring to private practice practitioners billing Medicare directly] and “hospitals” [referring to multiple settings such as SNF Part B, CORF, Outpatient PT/OT/SLP providers and Home Health Agencies], using bill types:

  • 22x (SNF Part B residents)
  • 23x (SNF Outpatient – Non-residents)
  • 75x (Comprehensive Outpatient Rehab Facility)
  • 74x (Outpatient Rehab Facility)
  • 34x (Home Health Agency)

Updated NCCI Edit Cheat Sheet Available

Who likes reviewing over 625, 000 rows of CPT codes to pick out the combinations for therapists?? Luckily, we do…so you don’t have to! We did the digging and created 2 cheat sheets:

  1. Private Practice
  2. SNF Part B, CORF, ORF, HHA

Here is a sample of the 7-page document:

To access the document for download, go to the Therapist Toolbox – Medicare Part B Section and select NCCI Edits. Or CLICK HERE

Additional Resources

Here are additional resources for your exploration:

NCCI Home Page

NCCI Excel Tables


Let’s hope these changes stay in place for a while!

As always, if you have any questions, please send them to our Just Ask Q&A Forum and we will be glad to help you.

In your corner,

Dolores Montero, PT, DPT, RAC-CT, RAC-CTA

SNF Rehab & MDS Compliance Team  |


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