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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.


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May 1, 2013 Volume 77, Number 5
Practice Management: NCCI: What It Is and How to Use It… Correctly Sharon Merrick, M.S., CCS-P

The January 2013 “Practice Management” column asked if 2013 would be the year of the audit. That article included a rundown of the entities that could be conducting pre- or post-payment reviews on the claims you submit for your services. As mentioned, the National Correct Coding Initiative (NCCI) is one of the more frequently cited reasons behind claims review. The NCCI was developed to promote correct coding and to prevent improper coding that can lead to improper payments. In this article, we will take a deeper look at the NCCI and what you need to know to make sure you are following it correctly.

The NCCI includes a volume of code pairs, termed “edits,” that set limits on which procedures can be reported together (Column One/Column Two edits). NCCI code pair edits are automated prepayment edits that prevent payment for one of the services when certain codes are reported together. In addition to code pair edits, the NCCI also includes Medically Unlikely Edits (MUEs) that limit the number of times a single specific procedure can be reported in a single date. NCCI edits apply to services provided by the same physician (or other professional) on the same patient on the same date. It is updated on a quarterly basis with new or revised edits posted on the Centers for Medicare & Medicaid Services website at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. The webpage includes a direct link to edits that have been added or changed since the previous version of the NCCI. That link is a very effective tool you can and should use. Remember, though, that you must follow edits that are in effect on the date a service was provided. The full set of edits includes the effective date and, when applicable, a deletion date.

All Medicare contractors follow the NCCI – and that includes the Recovery Audit Contractors (RACs). Many private payers use the NCCI as well. There are separate edits specific to Medicaid programs. That information may be accessed via the CMS website at www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html.

The Medicare NCCI includes a manual with chapters specific to a range of CPT® procedure codes. For example, the second chapter covers CPT® codes 00000-01999, which describe anesthesia services. Chapter two includes information about services that may be reported along with an anesthesia service, e.g., placement of a central venous line or an arterial line, performance of a postoperative pain procedure and transesophageal echocardiography.

Column One/Column Two Edits
A Column One/Column Two edit is a pairing of CPT® codes that would not ordinarily be reported together. Some edits will allow use of a modifier to override them under certain circumstances. Others are universally enforced. Column One/Column Two edits feature a modifier status indicator. An indicator of “0” means the edit is set in stone; an indicator of “1” acknowledges that there may be situations where both of the codes in the edit pair could be reported and paid.

The edits that pair the anesthesia codes (00100-01999) with evaluation and management (E/M) codes for the office/outpatient setting (99201-99205, 99211-99215) and for the inpatient setting (99221-99223, 99231-99233) are absolute (modifier status indicator = 0). The base unit value assigned to each anesthesia code includes the pre-anesthesia evaluation and the post-anesthesia visit(s). The edit would not be applied if the anesthesiologist sees the patient on a separate day for a reason unrelated to the anesthesia care, but be aware that some payers or RACs may still review such claims to confirm that the visit is not related to the anesthesia care provided. As an example, in February 2011, Performant Recovery (the Medicare Fee for Service RAC for Region A [CT, DC, DE, MD, NJ, NY, PA, MA, ME, NH, RI, VT]) listed “Anesthesia Care and Packaged Evaluation Management Services” as one of the issues it has under review. Performant’s description of the issue is: “Identification of overpayments associated with evaluation and management services billed the day prior to or day of anesthesia services by an anesthesiologist.

1) E/M services (as specifically defined in the IOM) billed the day prior to or day of anesthesia services without modifiers 24, 25 or 57.
2) E/M services billed the same day as 01996 without modifiers 24, 25 or 57.” www.dcsrac.com/IssuesUnderReview.aspx

Code or Modifier Description
24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period.
25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
57 Decision for surgery.
Source: CPT®

ASA soon posted a reminder to its members:
“We remind our members that if an anesthesiologist performs an evaluation and management (E/M) on the day prior to an anesthesia service, and that E/M is NOT the work covered by the pre-anesthesia examination/evaluation included in the base unit valuation, please note that in order to avoid automatic review by a Recovery Audit Contractor, s/he must append the appropriate modifier (typically either 24, 25 or 57) to that service. While automatic RAC review does not include review of the record, your documentation should be quite clear how it is NOT the pre-anesthesia exam/eval to support any indicated appeal. This is not a circumstance that happens very frequently since the base unit values include the pre-anesthesia exam/eval. An example of when such a service might be reportable is when there is a request from the surgeon for the anesthesiologist to make recommendations on preparing or optimizing the patient in advance of a possible surgical procedure. This would have to be something completely separate and above/beyond the work covered by the base units assigned to the anesthesia service.”

This leads to another very important point: Make sure that you use modifiers correctly. The NCCI includes edits that link codes describing anesthesia care with codes that describe procedures that can be performed to provide post-operative pain relief. Anesthesia for a total knee replacement is reported with code 01402. Code 01402 is a Column One code linked to various Column Two codes, including single and continuous intralaminar epidurals (codes 62310-62319). Because the modifier status indicator for these four edits is “1,” we know that it may be appropriate to report both the anesthesia and the epidural under the reasoning explained in Chapter 2 of the narrative manual (see above). If the criteria to separately report are met, then indicate such by appending a modifier to the Column Two code. In this case, use modifier 59 to tell the payer or reviewer that the epidural was distinct and separate from the anesthesia service.

An edit pairing a transforaminal epidural with fluoroscopic guidance also allows use of a modifier to override. Don’t do so automatically – make sure that the circumstances warrant it. A review of the full code descriptor for a lumbar transforaminal epidural seemingly makes clear that imaging guidance is bundled and not separately reportable. The CPT code set includes instructions that correlate; “Imaging guidance [fluoroscopy or CT] and any injection of contrast are inclusive components of 64479-64484.”

Code or Modifier Description
64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level.
77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid).
 59 Distinct procedural service.
Source: CPT®

Reporting 64483 along with 77003-59 may get past NCCI edits but could be problematic in a claim review. The intent of the edit is to allow use of fluoroscopic guidance (code 77003) when it is used to provide imaging guidance for a second procedure performed at the same time as a transforaminal epidural. Using a modifier to override an edit when criteria are not met will not hold up under review and can lead to more trouble beyond denial of a single claim.

Medically Unlikely Edits (MUEs)
MUEs are not procedure-to-procedure edits. They address the number of times one specific service can be reported. That is, they set limits on how many units of each service can be paid on a date of service. Many, but not all, MUEs are posted on the CMS website. Some MUEs are considered confidential between CMS and its contractors.

The ASA Statement of Intravascular Catheterization Procedures explains that there may be occasions where a patient could require two separate access sites to the central circulation resulting in reporting either two central line placements (code 36556) or a central line and a Swan Ganz catheter (code 93503). MUEs allow for this since the current MUE limit for placement of a central venous line (code 36556) is 2.

The April 15 deadline to file tax returns was not that long ago. The care and time required to make sure everything was properly documented and reported should still be fresh. In today’s environment, it is hard to tell what is under closer scrutiny – your IRS 1040 or your CMS 1500/837P. In either case, make sure you know as much as the auditor! If you want to know as much about the NCCI as a claims reviewer, download and read “How to Use the National Correct Coding Initiative (NCCI) Tools” from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf.

Sharon Merrick, M.S., CCS-P is ASA’s Director of Payment and Practice Management.

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