Procedure to Procedure Edits
The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services.
- Hospital PTP edits apply to types of bills subject to the outpatient code editor for the OPPS. These edits apply to outpatient hospital and other facility services including therapy providers in Part B SNFs , CORFs, outpatient physical therapy and speech language pathology providers and certain claims for home health agencies billing under type of bills 22X, 23X, 75X, 74X and 34X,
- Practitioner PTP edits apply to physician and ambulatory surgery center claims.
These edits are designed to prevent the inappropriate billing of services that should not be reported together because they are considered part of the same procedure or because the combination is not clinically appropriate.
In each PTP edit pair, the column 1 code represents the primary service, which is eligible for payment. The column 2 code represents a related or secondary service that may be considered part of the primary service and therefore is generally not separately payable.
There are circumstances where both services are justified as separate and distinct, a provider can use an appropriate NCCI PTP-associated modifier. This modifier indicates that the services were, in fact, independent of each other and both should be considered for reimbursement.
It's important for providers to ensure documentation supports the use of such modifiers to justify the medical necessity of reporting both codes together. Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include:
- Anatomic Modifiers: These modifiers specify the location or side of the body involved in the procedure. They help clarify when procedures were performed on different sites. Examples include:
- E1-E4: Eyelids
- FA, F1-F9: Fingers
- TA, T1-T9: Toes
- LT, RT: Left side, Right side
- LC, LD, RC: Coronary arteries
- LM, RI: Left main coronary artery, Ramus intermedius
- Global Surgery Modifiers: These modifiers indicate that a service rendered is separate from the global surgical package or within the package under specific conditions.
- 24: Unrelated evaluation and management service by the same physician during a post-operative period
- 25: Significant, separately identifiable evaluation and management service on the same day of the procedure
- 57: Decision for surgery
- 58: Staged or related procedure during the post-operative period
- 78: Unplanned return to the operating/procedure room during the post-op period
- 79: Unrelated procedure/service during the post-op period
- Other Modifiers: These modifiers identify various unique situations.
- 27: Multiple outpatient hospital evaluation and management encounters on the same date
- 59: Distinct procedural service
- 91: Repeat clinical diagnostic laboratory test
- XE: Separate encounter
- XS: Separate structure
- XP: Separate practitioner
- XU: Unusual non-overlapping service
These modifiers must be applied appropriately and supported by documentation to justify the need to bypass a PTP edit. Accurate use of these modifiers helps ensure compliance and accuracy in the billing process.
Note: The following modifiers are not NCCI PTP-associated modifiers and will not bypass an NCCI PTP edit.
- Modifiers 22: Increased Procedural Services
- Modifier 76: Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
- Modifier 77: Repeat Procedure by Another Physician or Other Qualified Health Care Professional
The PTP edit table does not include all possible combinations of correct coding edits or types of unbundling that exist.
Medicare beneficiaries cannot be billed for services denied based on PTP edits since these denials are based on incorrect coding rather than medical necessity, the provider cannot seek payment from the beneficiary with or without an ABN.
Revised 5/27/2025