This Policy is being updated from addressing only the CMS NCCI modifier indicator 0 (zero) code pairs, to include all CMS NCCI code pair editing.
To view the current version of this policy, see 00.01.56 National Correct Coding Initiative (NCCI) Modifier Indicator 0 (Zero) Procedure Code Pairs
In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
If procedure codes identified within the NCCI edit pair file are reported for the same individual on the same date of service, by the same provider, the Company will apply the associated NCCI edit for those code pairs.
Modifiers may be appended to these procedure code pairs when appropriate based on the CMS NCCI modifier indicators for each code pair edit.
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 the Company regardless of the presence of a modifier.
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.
Refer to the CMS NCCI file for procedure code pair edits and the associated modifier indicators.
This policy does not contain an all-inclusive list of procedure code editing applied by the Company. Procedure codes continue to be subject to Company claims adjudication logic, eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies.
The CMS CCI 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.
CMS assigns modifier indicators to each procedure code pair to identify when it may be appropriate to append a modifier to indicate that separate payment may be warranted. Modifier indicator 0 (zero) is assigned to procedure code pairs when there are no modifiers associated with NCCI edits that are allowed to be used with that given procedure code pair. For these procedure code pairs, there are no circumstances in which both procedures of the code pair should be reimbursed for the same member on the same day when performed by the same provider. Reporting a modifier does not override the NCCI edit for these procedure code pairs. Modifier indicator 1 is assigned to procedure code pairs to indicate that modifiers associated with NCCI are allowed with the code pair when appropriate. Modifier Indicator 9 is assigned to procedure code pairs when an NCCI edit does not apply to that code pair because the edit was deleted retroactively.
CMS updates the NCCI files quarterly.