CCI Edit Tables for Audiology Services

Updated for Quarter 3, 2021

The National Correct Coding Initiative (NCCI, or more commonly, CCI) is an automated edit system to control specific Current Procedural Terminology (CPT®) code pairs that can be reported by an individual provider on the same day for the same patient. This page provides Medicare Part B edits for code pairs commonly reported by audiologists. For questions, please contact reimbursement@asha.org. 

The Centers for Medicare & Medicaid Services (CMS) developed the edits for use on all Medicare Part B (outpatient) claims. They include CCI edits for provider-based services provided in clinics, private practices, and physician offices, and Outpatient Code Editor (OCE) edits for outpatient hospital and other facility-based services, including skilled nursing facilities, comprehensive outpatient rehabilitation facilities, and certain home health services. State Medicaid agencies are also required to use CCI edits, but may modify them to meet their own programmatic needs. Other third-party payers may also adopt CCI edits. Please check with non-Medicare payers regarding their use of CCI edits.

Audiologists should also be aware of Medically Unlikely Edit (MUE) restrictions, which are a subset of CCI edits that limit the number of times individual CPT codes may be billed on the same day, for the same patient. 

Understanding CCI and OCE Edits

Please see ASHA's overview of the NCCI system for additional information and resources, including appropriate use of modifiers. Audiologists should also review Chapter 1 of the official NCCI Policy Manual for detailed guidance from CMS. Chapter 11, Section H (Otorhinolaryngologic Services) of the manual provides additional guidance related to audiology services. Here are some key things audiologists need to know about CCI and OCE edits.

CMS updates CCI and OCE quarterly.

Audiologists should check this resource regularly because CMS makes quarterly updates, beginning on January 1 of each year. ASHA reviews the changes and makes updates to the audiology tables, as needed. The July 2021 quarterly updates did not include changes to audiology related code pairs.

Code pairs should apply to the provider, not the facility or office where services were provided.

According to CMS's NCCI FAQs, each code pair applies when reported by the same provider/supplier, for the same patient, on the same date of service. This may be complicated when billing under a clinic or facility's group number. Be sure the rendering provider's information is associated with each CPT code on the claim to avoid potential denials based on CCI or OCE edits.

Not all codes have a CCI or OCE edit.

Keep in mind that not all codes have a CCI or OCE edit. If you don't see an audiology-related code pair listed here, it means they aren't subject to CCI restrictions and can be billed on the same day without a modifier. However, remember that the NCCI system doesn't include all possible combinations of correct coding edits or types of unbundling that exist. You are obligated to code correctly even if edits don't exist to prevent use of an inappropriate code combination.

Learn when to appropriately use modifier -59 or its subcategory modifiers to bypass an edit.

This resource lists only code pairs with a CCI edit restriction and outlines whether the restriction can be bypassed with an NCCI-associated modifier. Although there are a number of NCCI-associated modifiers, modifier -59 (distinct procedural service) is the only one used with audiology-related edits. Some payers may require a more specific set of subcategory modifiers. Use these modifiers instead of (not in addition to) modifier -59.

• XE (separate encounter)
• XS (separate organ/structure)
• XP (separate practitioner)
• XU (unusual, non-overlapping service)

Use modifiers to bypass CCI edits sparingly and only when clinically justified. Don't append a modifier to a code pair solely to bypass a CCI edit if the clinical circumstances don't justify its use. In addition, don't use modifier -59 (or a subcategory modifier) if it isn't specifically required by the NCCI system, as this could cause denials. Please review CMS's resource on modifier -59 [PDF] for additional guidance.

How to Read the CCI and OCE Edit Tables

ASHA derived the following audiology related CCI and OCE edits from the complete lists of edits published on the CMS website. ASHA reviews CMS's quarterly updates and makes changes, as needed.

Column 1 lists the payable code. Column 1 codes should always be listed first on the claim.

Column 2 lists the code that is not payable when paired with the Column 1 code, unless a modifier is permitted. If permitted, append the modifier to the Column 2 code when submitting the claim.

Column 3 indicates whether a modifier is permitted to bypass the edit in both office and facility-based settings.

• "N" (No) means there is a CCI edit restriction on the code pair that can't be bypassed with a modifier. If you determine that it is clinically appropriate to provide both of these services on the same day, you may still report both codes on the claim. However, only the code listed in Column 1 will be paid and the Column 2 code will be denied.
• "Y" (Yes) means there is a CCI edit restriction but it may be bypassed by a modifier, if clinically appropriate. List the code in Column 1 first on the claim, followed by the code in Column 2. Attach modifier -59 (or appropriate subcategory modifier) to the CPT code listed in Column 2, when applicable.

Table 1: CCI and OCE Edits for Audiology Services 

Quarterly CCI edit changes are bolded in the table. There are no changes to this table for Q3.