What the results mean
Procedure-to-procedure (PTP) edits pair a column 1 code with a column 2 code. When both are billed for the same patient on the same day by the same provider, Medicare pays the column 1 code and denies the column 2 code, unless the edit allows a modifier.
- Modifier indicator 0: no modifier bypasses the edit. The column 2 code isn't paid.
- Modifier indicator 1: an NCCI-associated modifier (such as 59, XE, XS, XP, XU, or 25 on an E/M service) can bypass the edit, but only when the documentation supports a separate and distinct service.
Medically Unlikely Edits (MUEs) set the most units of a code a provider would normally report for one patient on one day. The MUE adjudication indicator (MAI) says how the limit is applied:
- MAI 1: claim line edit. Units above the limit on one line are denied. Extra units may be reported on separate lines with an appropriate modifier (for example 76, 77, 91, RT/LT).
- MAI 2: date of service edit based on policy. The limit is absolute for the day.
- MAI 3: date of service edit based on clinical judgment. Units above the limit are denied, but may be paid on appeal with documentation.
More on bypassing an edit for an E/M visit: Modifier 25 billing.
How the check works
The tool uses the CMS Medicare NCCI practitioner PTP edits and the practitioner services MUE table, and checks the two codes in both directions. Only edits in effect for the current quarter are included.
This tool covers Medicare NCCI edits for practitioner claims only. It doesn't cover hospital outpatient or DME edits, Medicaid NCCI, or commercial payer rules, and it isn't coding advice. CPT is a registered trademark of the American Medical Association; code descriptions aren't shown. Always confirm against the CMS files and the documentation.