Here’s Why Ignoring NCCI Modifier Indicator Updates Could Cost You

Modifier indicator changes are an easy-to-miss update that happen every quarter for Medicare’s practitioner National Correct Coding Initiative (NCCI) edits. But overlooking these changes can be costly. The modifier indicator lets you know whether you may override the edit using a modifier, and getting it wrong means either denials or lost reimbursement opportunities. Here’s a closer look at modifier indicators for Medicare NCCI edits and what a change means for your coding.

Know Where to Find Indicators

The NCCI edits table uses numbers in the Modifier column to let you know the NCCI rules that apply to a particular code pair. Whether you use an NCCI edits Excel file, NCCI data files integrated with your systems, or an online NCCI checker tool, make sure you have access to this modifier indicator information.

Table 1 shows some of the columns from the Q1 2018 NCCI edits file, with the Modifier column from Q4 2017 added, too.

Table 1: Sample NCCI Edits
Column 1 Column 2 Effective Date Deletion Date Modifier

(Q4 2017)

Modifier

(Q1 2018)

* = no data 0 = not allowed

1 = allowed

9 = not applicable

22319 38220 20140101 * 1 0
64633 64484 20170401 * 0 1
93653 93623 20130101 20130101 9 9

The column 1 and column 2 codes on a row show you the procedure to procedure (PTP) edit. Using an example from Table 1, if a provider reports both column 1 code 22319 and column 2 code 38220 for the same patient on the same date, Medicare will deny the column 2 code. The column 1 code will be eligible for payment.

The potential impact on reimbursement is why it’s important to apply the NCCI Medicare edits and to understand how the Modifier column affects your reporting options.

Define 0, 1, 9 for More Accurate Coding

Let’s take the modifier indicators one at a time. We’ll start with modifier indicator 1 because it’s easier to understand 0 once you’ve grasped what 1 means for the NCCI edits physicians use.

1: Modifier indicator 1 means it’s possible to override (aka bypass or unbundle) the edit by using NCCI-associated modifiers. Big flashing warning: You should override the edit only when coding rules and clinical circumstances support doing so, such as when separate sites or separate sessions are involved.

The full list of NCCI-associated modifiers is in the policy manual on the NCCI edits Medicare site. Some examples include anatomic modifiers LT and RT, global surgery modifiers 24 and 25, and distinct-service modifier 59.

0: Modifier indicator 0 means that you are never allowed to override the edit. If you report the two codes together, even with an NCCI modifier on the column 2 code, Medicare will deny the column 2 code.

Examples of changes: As Table 1 shows, the 22319/38220 and 64633/64484 edits had modifier indicator changes in Q1 2018.

  • The indicator for 22319 (spine fracture treatment) and 38220 (bone marrow aspiration) changed from 1 (allowed) to 0 (not allowed). On Jan. 1, 2018, new code +20939 (Bone marrow aspiration for bone grafting, spine surgery …) became available to report in conjunction with 22319. So the indicator change helps ensure you don’t use the wrong code for aspiration with spine surgery.
  • The edit for 64633 (single cervical or thoracic facet joint nerve destruction) and +64484 (additional lumbar or sacral transforaminal epidural injection) changed the indicator from 0 to 1. The primary code for +64484 is 64483, which also has an edit with 64633 with indicator 1. Remember that you should override the edits only when clinically appropriate.

9: Occasionally, NCCI deletes edits retroactively, making it as if they never existed. In Table 1, you can see that the 93653/93623 edit has the same date in the Effective Date and Deletion Date columns. Typically, retroactive deletion occurs when the edit was an error. The modifier indicator is 9 (not applicable) because when there’s no edit, there’s no need for a modifier indicator. If you received a denial based on an edit that later undergoes a retroactive deletion, consider bringing the claim to your payer’s attention to receive payment.

Bottom line: If checking the modifier indicator for NCCI edits isn’t on your clean-claim checklist, it needs to be. Indicators can be the clue you need to reduce denials and increase reimbursement.

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