This page provides an overview of the National Correct Coding Initiative (NCCI) system, which controls same-day billing requirements for Medicare and Medicaid services provided by audiologists and speech-language pathologists (SLPs). This resource also includes audiology and speech-language pathology specific edit lists.
Please contact firstname.lastname@example.org for specific coding questions related to audiology and speech-language pathology services.
The NCCI is an automated edit system to control specific Current Procedural Terminology (CPT® American Medical Association) code pairs that can or cannot be billed by an individual provider on the same day for the same patient (commonly known as CCI edits). The Centers for Medicare & Medicaid Services (CMS) developed the system for use in all Medicare Part B and Medicaid claims for outpatient services. CCI edits apply to provider-based services in outpatient settings such as clinics, private practices, and physician offices. Outpatient Code Editor (OCE) edits—a subset of the CCI system—apply to facility-based services, such as hospital outpatient or SNF Part B services. Typically, the OCE edits for audiology and speech-language pathology are similar to those in the CCI system.
The goal of the NCCI system is to promote correct coding and prevent inappropriate payment by disallowing code pairs that are "mutually exclusive", are considered to be components of more comprehensive services, or reflect services that are otherwise inappropriate to be delivered to the same patient on the same day. Mutually exclusive code pairs are those services that can’t reasonably be performed together during the same patient encounter due to anatomic considerations or the nature of the service. Codes representing component services may not be reported with CPT codes representing more comprehensive services. Not all CPT codes have a CCI edit.
Examples of mutually exclusive code pairs
Examples of comprehensive/component code pairs
In addition to identifying code pairs that may never be billed together, the CCI system also identifies certain services that aren’t typically performed together, but for which there may be times when it’s clinically justified to provide these services to the same patient on the same day. In those instances, CMS will indicate that a modifier is required to bypass a code pair edit and allow same-day billing. Modifier -59 [PDF] indicates "distinct procedural service" and is the most appropriate modifier for code pairs commonly billed by audiologists and SLPs. Some payers may require clinicians to use subcategory modifiers instead of modifier -59 because they provide additional detail regarding how the services are distinct. However, this is not as common, or payers may allow claims to include either modifier -59 or one of the more specific subcategory modifiers, as outlined below.
Clinicians should 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. Chapter 1 of the NCCI Policy Manual provides additional guidance on the use of modifiers with CCI edits. Clinicians should also check directly with payers regarding modifiers for CCI edits.
The CCI system also includes a set of edits called Medically Unlikely Edits (MUEs) for Medicare Part B and Medicaid claims. An MUE for a procedure code is the maximum number of times that the code can be billed for the same patient on the same day. MUEs apply to both provider and hospital-based services, as well as durable medical equipment (DME). Not all CPT codes have an MUE. Chapter 1 of the NCCI Policy Manual provides additional guidance on MUEs.
ASHA compiled the following lists of audiology and speech-language pathology specific CCI edits and MUEs from the full list of Medicare edits published on the CMS website. CMS updates the CCI/OCE edits and MUEs quarterly. ASHA reviews the quarterly CMS updates and revises these lists as needed. Note that not all codes have an MUE and/or CCI edit.
CMS provides further detail and guidance related to CCI edits in the official NCCI Policy Manual, which is updated annually. Chapter 11 of the manual includes guidance on audiology and speech-language pathology services.
Although State Medicaid agencies are also required to use CCI edits, they 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.
The following resources include the full lists of CCI edits and MUEs from CMS, as well as official guidance and policy manuals.
Medicaid programs may adapt the CMS list to meet specific programmatic needs. Check directly with your individual state Medicaid agency for the most accurate list.