NCCI Edits Tool for Hospital and Physician Services

Last updated on 11/4/24 | First published on 3/2/21 | Literature review current through Oct. 2024 [cite]

Authors: WoundReference Editors , more...

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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 for the interactive Tool below: 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.
Add-on codes follow the same rule as the associated primary service code (e.g. add-on code 11045 follows the same rule as 11042)

* 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"

 Printable Table: NCCI Edits

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	11042, 11043, 11044	11102	NO - Report applicable 1104XX code(s) only	YES - Report both services, add NCCI modifier	YES
Surgical Debridement	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, 15275, 15276, 15277, 15278	11042, 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
TCOM	93922, 93923		May be provided with any other procedure listed in this document		YES
HBOT	G0277		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
Vein ablation	36475	11042 / 11043 / 11044	YES - Report BOTH applicable procedures	YES - Report both services	YES
Vein ablation	36475	97597	YES - Report BOTH applicable procedures	YES - Report both services	YES
Vein ablation	36475	97605, 97606, 97607, 97608	YES - Report BOTH applicable procedures	YES - Report both services	YES
Vein ablation	36475	15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278	YES - Report BOTH applicable procedures	YES - Report both services	YES
Vein ablation	36475	C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278	YES - Report BOTH applicable procedures	YES - Report both services	N/A
Vein ablation	36475	11055, 11056, 11057	YES - Report BOTH applicable procedures	YES - Report both services	YES
Vein ablation	36475	17250	YES - Report BOTH applicable procedures	YES - Report both services	YES
Vein ablation	36475	93922 / 93923	YES - Report BOTH applicable procedures	YES - Report both services	YES
Vein ablation	36475	29580 / 29581	NO - Report 36475 code only	YES - Report both services	YES
Vein ablation	36475	29445	YES - Report BOTH applicable procedures	YES - Report both services	YES
Vein ablation	36475	93970	NO - Report 36475 code only	NO - These codes cannot be billed together. Only code 36475 can be billed	YES
Vein ablation	36475	93971	NO - Report 36475 code only	YES - Report both services	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
Additional Procedural Codes	97610	97035, 97607, 97608	NO - Report 97610 only	YES - Report both services, add NCCI modifier	YES
Additional Procedural Codes	97610	97602	NO - Report 97610 only	YES - Report both services, add NCCI modifier	N/A
Additional Procedural Codes	11000, 11004, 11005, 11006, 11010, 11011, 11012, 11042, 11043, 11044, 11720, 11721, 97597, 97598, 97605, 97606	97610	NO - Report 97610 only	YES - Report both services, add NCCI modifier	YES
Additional Procedural Codes	G0245, G0246, G0247	97610	NO - Report 97610 only	NO - Report 97610 only	YES
Additional Procedural Codes	G0456, G0457	97610	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.

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NCCI Edits Tool for Hospital and Physician Services

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