Understanding NCCI edits
What is NCCI?
The National Correct Coding Initiative (NCCI) is a set of coding edits developed by CMS (Centers for Medicare & Medicaid Services) to:
Prevent improper payment of services that shouldn't be reported together
Promote accurate coding and reduce overbilling
Two Types of NCCI Edits:
PTP Edits (Procedure-to-Procedure)
Tell you which codes should not be reported together because one is considered:
A component of the other
Inherently included in the comprehensive service
Can be bypassed with a modifier in some cases
2. MUEs (Medically Unlikely Edits)
Define the maximum number of units allowed for a CPT/HCPCS code on a single date of service.
Used to catch overreporting or data entry errors.
How to access NCCI Edits
CMS releases quarterly updates (January, April, July, and October) for both PTP and MUE edits.
Official CMS Website:
Medicare National Correct Coding Initiative (NCCI) Edits - CMS’s (NCCI) homepage and overview, includes:
How to Use NCCI Tools booklet (PDF) - a guide on How to Use the Medicare NCCI Tools per CMS
Medicare NCCI Procedure to Procedure (PTP) Edits - includes the Quarterly Version Update Changes per 2025, Hospital and Practitioner Edits
Medicare NCCI Coding Policy Manual - a comprehensive document published annually by CMS that explains the rules and rationale behind NCCI edits. It is a companion to the NCCI edit files (Procedure-to-Procedure and MUEs) and gives detailed policy guidance on how to code correctly and when modifiers can be used.
Where Else to Find Them:
In a coding software (e.g., Codify, EncoderPro, TruCode, FindACode, etc.)
Payer websites may have their own versions (especially Medicaid or commercial plans)
Understanding the Edit Table
The NCCI contains two types of tables on the CMS website: one table of edits for physicians/practitioners, and one table of edits for outpatient hospital services.
Modifier Indicators (PTP Edits)
Common Modifiers Used with NCCI
CMS prefers X modifiers, but some commercial payers still use 59.
How to Look Up NCCI Edits for CPT Codes
Go to the Official CMS NCCI Edits Page:
Scroll to “PTP Coding Edits”
Look for the section called “Procedure-to-Procedure (PTP) Coding Edits” under "Downloads." You will see quarterly update files like:
NCCI PTP Edits – Practitioner – CSV or Excel format
Choose the most recent quarter (e.g., "2025 Q2 Practitioner PTP Edits")
Click to download the Excel file (.xlsx) — it contains all the code pair edits.
EXAMPLE: to find the NCCI edits for codes 31622 (bronchoscopy) and 39000 (mediastinotomy, cervical approach), I would select “Practitioner PTP Edits v311r0 (674,813 Records) 25685/01810 -- 38760/G0471 (ZIP)”
Open the File and Use “Find” or Filter
Once you’ve opened the Excel file:
Press Ctrl+F (find) or use Filter tools
Type your code (i.e., 31622) in Column 1 or Column 2 to locate code pair edits involving this code
4. Read the Modifier Indicator
Find the column labeled “Modifier Indicator” (usually column G or H)
If it says “1” → You may use a modifier (e.g., 59 or XU) if appropriate
If it says “0” → You cannot override the edit with a modifier
If it says “9” → Edit has been deleted
5. Determine if Modifier Use is Justified
If you find the edit and the indicator is "1," now ask:
Was the bronchoscopy diagnostic and not integral to the mediastinotomy (surgical)?
Were the services separate in intent, site, or session?
Is it well-documented?
If yes to all → You can report both codes, appending modifier 59 (or XS) to 31622.
***Bonus Tip: CMS Policy Manual Back-Up
For more context on the bundling, open the NCCI policy Manual - Chapter 5 (Respiratory System) and look under bronchoscopy and surgical bundling rules for added clarity.
