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NCCI Edits for Hospital and Physician Services

NCCI Edits for Hospital and Physician Services

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NCCI Edits for Hospital and Physician Services

NCCI Procedure-to-Procedure (PTP) code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services. Accurate coding and reporting of services are critical aspects of proper billing. Service that is denied based on PTP code pair edits may not be billed to Medicare beneficiaries.[1][2] A PTP code pair edit simply represents two codes that should not be reported together, unless an appropriate modifier is used.[2]

Instructions: 1. Select number of entries (rows) to be displayed on the table. 2. Use the "Search" field to find a specific procedure code. The table indicates if codes listed in 'Procedure 1' and 'Procedure 2' are eligible for payment when reported together:

  • If the codes listed in "Procedure 1" and "Procedure 2" cannot be reported together when provided at the SAME location (wound), then this combination is a PTP code pair edit. That is, if a provider submits the two codes of an edit pair for payment for the same beneficiary on the same date of service, the "Procedure 1" code is eligible for payment and the "Procedure 2" code is denied. However, if both codes are clinically appropriate and an appropriate NCCI-associated modifier is used, the codes in both columns are eligible for payment. Supporting documentation must be in the beneficiary’s medical record. See sections 'National Correct Coding Initiative Edits (NCCI)' and 'Modifiers for Wound Care and Hyperbaric Oxygen Therapy' in topic "Coding and Billing Essentials in Wound Care".
  • If the table indicates that the code listed in "Procedure 1" and "Procedure 2" can be reported together, this combination is not a PTP code pair edit and both codes are eligible for payment when reported for the same beneficiary on the same date of service.


* Hospital CCI editing tools, your Medicare Administrative Contractor (MAC) and Coverage Determinations should serve as the definite source of billing guidelines. Abbreviations: CTP: cellular and/or tissue products, TCOM: transcutaneous oximetry, HBOT: hyperbaric oxygen therapy, NPWT: negative pressure wound therapy. See code descriptions in "HCPCS/CPT Codes Commonly Utilized in Wound Care and HBOT"

Procedure type Procedure 1 Procedure 2 Can both services be reported if provided at the SAME location (wound)? Can both services be reported if provided at SEPARATE wounds and/or anatomical locations? Does rule apply to Providers?
Surgical Debridement 11042, 11043, 11044 11042, 11043, 11044 NO - Report applicable CPT code for deepest depth debridement only YES - Report both services, add NCCI modifier YES
Surgical Debridement 11055, 11056, 11057 11042, 11043, 11044 NO - Report applicable 11055-11057 code only YES - Report both services, add NCCI modifier YES
Surgical Debridement 11102, 11103, 11104, 11105, 11106, 11107 11042, 11043, 11044 NO - Report applicable 111XX code(s) only YES - Report both services, add NCCI modifier YES
Surgical Debridement 15271, 15272, 15273, 15274, 15725, 15276, 15277, 15278 11042 NO - Report applicable 15271-15278 code(s) only YES - Report both services, add NCCI modifier YES
Surgical Debridement 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 11043, 11044 NO - Report applicable 15271-15278 code(s) only YES - Report both services, add NCCI modifier YES
Surgical Debridement C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 11042 NO - Report applicable C5271-05278 code(s) only YES - Report both services, add NCCI modifier N/A
Surgical Debridement 11043, 11044 C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 YES - Report BOTH applicable procedures YES - Report both services N/A
Surgical Debridement 11042, 11043, 11044 17250 NO - Report applicable 11042-11044 code only YES - Report both services, add NCCI modifier YES
Surgical Debridement 11042, 11043, 11044 29445 NO - Report applicable 11042-11044 code only YES - Report both services, add NCCI modifier YES
Surgical Debridement 11042, 11043, 11044 29580 NO - Report applicable 11042-11044 code only YES - Report both services, add NCCI modifier YES
Surgical Debridement 11042, 11043, 11044 29581 NO - Report applicable 11042-11044 code only YES - Report both services, add NCCI modifier YES
Surgical Debridement 11042, 11043, 11044 97597, 97598 NO - Report applicable 11042-11044 code only YES - Report both services, add NCCI modifier YES
Surgical Debridement 11042, 11043, 11044 97602 NO - Report applicable 11042-11044 code only YES - Report both services, add NCCI modifier N/A
Surgical Debridement 11042, 11043, 11044 97605, 97606, 97607, 97608 YES - Report BOTH applicable services YES - Report both services YES
Debridement open wound 11055, 11056, 11057 97597 NO - Report applicable 11055-11057 code only YES - Report both services, add NCCI modifier YES
Debridement open wound 11102, 11103, 11104, 11105, 11106, 11107 97597 NO - Report applicable 111XX code(s) only YES - Report both services, add NCCI modifier YES
Debridement open wound 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 97597 NO - Report applicable 15271-15278 code(s) only YES - Report both services, add NCCI modifier YES
Debridement open wound C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 97597 NO - Report applicable C5271-05278 code(s) only YES - Report both services, add NCCI modifier N/A
Debridement open wound 97597 17250 NO - Report applicable 97597 code only YES - Report both services, add NCCI modifier YES
Debridement open wound 97597 29445 NO - Report applicable 97597 code only YES - Report both services, add NCCI modifier YES
Debridement open wound 97597 29580 NO - Report applicable 97597 code only YES - Report both services, add NCCI modifier YES
Debridement open wound 97597 29581 NO - Report applicable 97597 code only YES - Report both services, add NCCI modifier YES
Debridement open wound 11042, 11043, 11044 97597, 97598 NO - Report applicable 11042-11044 code only YES - Report both services, add NCCI modifier YES
Debridement open wound 97597 97602 NO - Report applicable 97597 code only NO - Report 97597 only N/A
Debridement open wound 97597 97605, 97606, 97607, 97608 NO - Report applicable 97597 code only YES - Report both services, add NCCI modifier YES
Non-selective debridement 11055, 11056, 11057 97602 NO - Report applicable 11055-11057 code only YES - Report both services, add NCCI modifier N/A
Non-selective debridement 11102, 11103, 11104, 11105, 11106, 11107 97602 NO - Report applicable 111XX code(s) only YES - Report both services, add NCCI modifier N/A
Non-selective debridement 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 97602 NO - Report applicable 15271-15278 code(s) only YES - Report both services, add NCCI modifier N/A
Non-selective debridement C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 97602 NO - Report applicable C5271-05278 code(s) only YES - Report both services, add NCCI modifier N/A
Non-selective debridement 17250 97602 NO - Report 17250 only YES - Report both services, add NCCI modifier N/A
Non-selective debridement 97602 29445 NO - Report 97602 only YES - Report both services, add NCCI modifier N/A
Non-selective debridement 97602 29580 NO - Report 97602 only YES - Report both services, add NCCI modifier N/A
Non-selective debridement 97602 29581 NO - Report 97602 only YES - Report both services, add NCCI modifier N/A
Non-selective debridement 97597 97602 NO - Report applicable 97597 code only NO - Report applicable 97597 code only N/A
Non-selective debridement 97605, 97606 97602 NO - Report applicable 97605 or 97606 code only NO - Report applicable 97605 or 97606 code only N/A
Non-selective debridement 97602 97607, 97608 NO - Report 97602 only NO - Report 97602 only N/A
Application of skin substitute (CTP) 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 11055, 11056, 11057 YES - Report BOTH applicable procedures YES - Report both services YES
Application of skin substitute (CTP) C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 11055, 11056, 11057 YES - Report BOTH applicable procedures YES - Report both services N/A
Application of skin substitute (CTP) 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 11102, 11103, 11104, 11105, 11106, 11107 YES - Report BOTH applicable procedures YES - Report both services YES
Application of skin substitute (CTP) C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 11102, 11103, 11104, 11105, 11106, 11107 YES - Report BOTH applicable procedures YES - Report both services N/A
Application of skin substitute (CTP) 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 17250 YES - Report BOTH applicable procedures YES - Report both services YES
Application of skin substitute (CTP) C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 17250 YES - Report BOTH applicable procedures YES - Report both services N/A
Application of skin substitute (CTP) 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 29445 NO - Report applicable 15271-15278 code(s) only YES - Report both services, add NCCI modifier YES
Application of skin substitute (CTP) C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 29445 NO - Report applicable C5271-05278 Code(s) only YES - Report both services, add NCCI modifier N/A
Application of skin substitute (CTP) 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 29580 NO - Report applicable 15271-15278 code(s) only YES - Report both services, add NCCI modifier YES
Application of skin substitute (CTP) C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 29580 NO - Report applicable C5271-05278 Code(s) only YES - Report both services, add NCCI modifier N/A
Application of skin substitute (CTP) 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 29581 NO - Report applicable 15271-15278 code(s) only YES - Report both services, add NCCI modifier YES
Application of skin substitute (CTP) C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 29581 NO - Report applicable C5271-05278 Code(s) only YES - Report both services, add NCCI modifier N/A
Application of skin substitute (CTP) 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 97605, 97606, 97607, 97608 NO - Report applicable 15271-15278 Code(s) only YES - Report both services, add NCCI modifier YES
Application of skin substitute (CTP) C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 97605, 97606, 97607, 97608 NO - Report applicable C5271-05278 code(s) only YES - Report both services, add NCCI modifier N/A
NPWT 11055, 11056, 11057 97605, 97606, 97607, 97608 NO - Report applicable 11055-11057 code only YES - Report both services, add NCCI modifier YES
NPWT 97605, 97606, 97607, 97608 11102, 11103, 11104, 11105, 11106, 11107 YES - Report BOTH applicable procedures YES - Report both services YES
NPWT 17250 97605, 97606, 97607, 97608 NO - Report 17250 only YES - Report both services, add NCCI modifier YES
NPWT 97605, 97606, 97607, 97608 29445 YES - Report BOTH applicable procedures YES - Report both services YES
NPWT 97605, 97606, 97607, 97608 29580 YES - Report BOTH applicable procedures YES - Report both services YES
NPWT 97605, 97606, 97607, 97608 29581 YES - Report BOTH applicable procedures YES - Report both services YES
Chemical cauterization & compression 17250 29445 YES - Report BOTH applicable procedures YES - Report both services YES
Chemical cauterization & compression 17250 29580 YES - Report BOTH applicable procedures YES - Report both services YES
Chemical cauterization & compression 17250 29581 YES - Report BOTH applicable procedures YES - Report both services YES
TCOM93922, 93923

May be provided with any other procedure listed in this document

YES
HBOTG0277

May be provided with any other procedure listed in this document

YES
Autograft/ Tissue Cultured Autograft 15100, 15110, 15115, 15120 11042, 11043, 11044 NO - Report applicable 15100, 15110, 15115 or 15120 code only YES - Report both services, add NCCI modifier YES
Autograft/ Tissue Cultured Autograft 15100, 15110, 15115, 15120 97597 NO - Report applicable 15100, 15110, 15115 or 15120 code only YES - Report both services, add NCCI modifier YES
Autograft/ Tissue Cultured Autograft 15100, 15110, 15115, 15120 97602 NO - Report applicable 15100, 15110, 15115 or 15120 code only YES - Report both services, add NCCI modifier N/A
Autograft/ Tissue Cultured Autograft 15100, 15110, 15115, 15120 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 YES - Report BOTH applicable procedures YES - Report both services YES
Autograft/ Tissue Cultured Autograft 15100, 15110, 15115, 15120 C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 YES - Report BOTH applicable procedures YES - Report both services N/A
Autograft/ Tissue Cultured Autograft 15100, 15110, 15115, 15120 97605, 97606, 97607, 97608 NO - Report applicable 15100, 15110, 15115 or 15120 code only YES - Report both services, add NCCI modifier YES
Autograft/ Tissue Cultured Autograft 15100, 15110, 15115, 15120 17250 YES - Report BOTH applicable procedures YES - Report both services YES
Autograft/ Tissue Cultured Autograft 15100, 15110, 15115, 15120 93922, 93923 YES - Report BOTH applicable procedures YES - Report both services YES
Vein ablation 36478 11042, 11043, 11044 YES - Report BOTH applicable procedures YES - Report both services YES
Vein ablation 36478 97597 YES - Report BOTH applicable procedures YES - Report both services YES
Vein ablation 36478 97605, 97606, 97607, 97608 YES - Report BOTH applicable procedures YES - Report both services YES
Vein ablation 36478 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278 YES - Report BOTH applicable procedures YES - Report both services YES
Vein ablation 36478 C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278 YES - Report BOTH applicable procedures YES - Report both services N/A
Vein ablation 36478 11055, 11056, 11057 YES - Report BOTH applicable procedures YES - Report both services YES
Vein ablation 36478 17250 YES - Report BOTH applicable procedures YES - Report both services YES
Vein ablation 36478 93922, 93923 YES - Report BOTH applicable procedures YES - Report both services YES
Vein ablation 36478 29580 NO - Report 36478 only YES - Report both services, add NCCI modifier YES
Vein ablation 36478 29581 NO - Report 36478 only YES - Report both services, add NCCI modifier YES
Vein ablation 36478 93970 NO - Report 36478 only NO - Report 36478 only YES
Vein ablation 36478 93971 NO - Report 36478 only YES - Report both services, add NCCI modifier YES
Burn debridement 16020, 16025, 16030 29445 YES - Report BOTH applicable procedures YES - Report both services  YES
Burn debridement 16020, 16025, 16030 29580 YES - Report BOTH applicable procedures YES - Report both services  YES
Burn debridement 16020, 16025, 16030 29581 YES - Report BOTH applicable procedures YES - Report both services YES 
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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.
Topic 1605 Version 1.0