Frequently Asked Questions

NCCI Procedure-to-Procedure (PTP) edits prevent inappropriate payment of services that should not be reported together. They are correct-coding edits, not medical-necessity edits, and are not based on diagnosis codes.

NCCI PTP edits and MUEs are updated at least quarterly by CMS.

PTP edits flag code pairs that should not be reported together. MUE edits flag the maximum units of service for a single HCPCS/CPT code on the same date of service.

Yes. Submit a Medicare PTP reconsideration request to NCCIPTPMUE@cms.hhs.gov with the exact code pairs, justification, and supporting documentation.

An MUE is the maximum units of service that a provider would normally report for a single beneficiary on a single date of service for a given HCPCS/CPT code.

MAI 1 is a claim-line edit (modifiers can split units across lines). MAI 2 is an absolute date-of-service limit that is never payable above. MAI 3 is a date-of-service limit that is appealable with documentation in rare cases.

For MAI 1 and MAI 3, yes. If you have adequate medical-necessity documentation, MACs may pay units above the MUE on appeal. MAI 2 is non-appealable.

Pre-op visits (1 day before), the procedure itself, and post-op visits within the global window are bundled into a single payment.

Codes ending in 000 are 0 days (endoscopies and minor procedures). Codes ending in 010 are 10 days (other minor surgeries). Codes ending in 090 are 90 days (major surgeries, plus 1 pre-op day for 92 total).

The surgeon appends modifier 54 (surgical care only). The provider giving post-op care appends modifier 55. Each bills their portion of the global fee separately.

No, with one rare exception (critical care add-on +99292 between same-practice providers). If billed alone, the add-on code is denied.

The add-on code is automatically denied as well. Payment is conditional on a paid primary procedure.

No. Add-on codes are explicitly modifier-51-exempt. Most do not require any modifier.

Type I codes are locked to a specific list of primary codes. Type II have no fixed primary list — payers decide. Type III have a non-exhaustive list with payer flexibility.

Use modifier 50 with 1 unit on a single line for procedures performed on both sides. Use LT/RT only when the procedure is performed on one side of a paired organ. Do not combine modifier 50 with LT or RT.

Codes that are already inherently bilateral (for example, the description contains the word “bilateral”). Adding modifier 50 would be redundant and may trigger a duplicate denial.

Standard adjustment is 150% of the fee schedule (with BILAT SURG indicator 1). Some procedures (for example, ophthalmoscopy 92225/92226) pay 100% per side.

NCDs are nationwide coverage policies issued by CMS. LCDs are issued by Medicare Administrative Contractors (MACs) and apply only within their jurisdiction. LCDs cannot contradict an NCD.

When CMS has not issued an NCD on a service, MACs may issue an LCD to clarify coverage in their region.

Medicare covers items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury, and within a Medicare benefit category.

Modifier 25 is for a significant, separately identifiable E/M service on the same day as a procedure. Modifier 59 is for a distinct procedural service that is separate from another procedure. Do not swap them.

Always use the more specific X-modifier when applicable. Modifier 59 should only be used when no specific X-modifier fits.

The OIG has documented widespread misuse. Providers append it routinely whenever a procedure is performed on the same day, even when the E/M service is not truly separately identifiable.

The same provider submits the same CPT code for the same patient and date more than once. Common causes include manual resubmission, software glitches, or missing modifiers on bilateral or repeat procedures.

Mark it as a corrected claim with the original claim ID and the reason for the correction. Do not just resubmit it as a new claim.

The second-submitted claim will deny as a duplicate. The second provider must include documentation or a modifier showing the service was independently rendered.

The highest-RVU procedure pays 100%. Subsequent procedures performed in the same encounter pay a reduced rate (commonly 50% on the second procedure for surgery; varies by service type).

Only if the providers are in the same group practice billing for the same patient on the same day.

No. E/M services properly appended with modifier 25 are excluded from MPPR.