Administrative and Billing Updates
National Correct Coding Initiative (NCCI) edits and use of Modifier -59
Regence utilizes Medicare-published relative value units and incorporates Medicare's NCCI edits to determine our fee allowables. We follow the Centers for Medicare & Medicaid Services' (CMS') rules on the correct use of Modifier -59. Although some professional medical organization recommendations differ from these guidelines, the national coding standards set by CMS will be applied to Regence claims.
Each NCCI edit has an assigned modifier indicator which is listed on the CMS Web site. A modifier indicator helps to clarify when a modifier should be billed with a particular code.
Modifier -59 may be valid when attached to a code that is distinct or independent from the other services performed on the same date of service. The guidelines below should be considered in order to determine if Modifier -59 is appropriate for use. If the NCCI code pair edit has a:
- '0' modifier indicator, then there is no appropriate modifier to use to bypass the code pair edit
- '1' modifier indicator and is in the mutually exclusive table, the only valid use of Modifier -59 is when the procedure occurred at a distinctly separate session or encounter
- '1' modifier indicator and the procedure reported is performed in separate patient encounters/sessions or different anatomic sites (including different organs or different lesions on the same organ; but not including treatment of contiguous structures of the same organ)
An example of a code pair component denial from NCCI is
when edits for CPT 29826 Decompression of subacromial
space with partial acromioplasty, with or without coracoacromial
release are billed with CPT 23412 Repair
of ruptured musculotendinous cuff (e.g., rotator cuff) open; chronic.
This edit has a superscript of '1', indicating that this code pair
edit is based on specific rationale and that CPT 29826 is
considered a component of CPT 23412 in most circumstances;
and, therefore, is not eligible for an additional allowance.
A joint procedure may be performed solely by open technique, solely by arthroscopic technique, or by surgery through a combination of open technique and arthroscopic technique. In all three examples, Modifier -59 is appropriate for use only when two separate joints are involved in the two procedures.
