CORRECT CODING INITIATIVE’S 81001 Ncci Correspondence Language Manual

User Manual: 81001

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TABLE OF CONTENTS

NATIONAL CORRECT CODING INITIATIVE’S

(NCCI)

GENERAL CORRESPONDENCE LANGUAGE

AND

SECTION-SPECIFIC EXAMPLES

(FOR NCCI PROCEDURE TO PROCEDURE (PTP)

EDITS AND MEDICALLY UNLIKELY EDITS

(MUE))

EFFECTIVE: April 1, 2014*

*INCLUDES 2014 HCPCS/CPT CODES

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Revision Date (Medicare): 4/1/2014

Current Procedural Terminology (CPT) codes, descriptions and other

reserved.

CPT® is a registered trademark of the American Medical Association.

Applicable FARS\DFARS Restrictions Apply to Government Use.

Fee schedules, relative value units, conversion factors and/or related

components are not assigned by the AMA, are not part of CPT, and

the AMA is not recommending their use. The AMA does not directly

or indirectly practice medicine or dispense medical services. The

AMA assumes no liability for the data contained or not contained

herein.

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Revision Date (Medicare): 4/1/2014

TABLE OF CONTENTS

Section Page

Introduction 6

General Correspondence Language for NCCI PTP Edits

Standard preparation/monitoring services for anesthesia 9

HCPCS/CPT procedure code definition 9

CPT Manual or CMS manual coding instruction 9

Mutually exclusive procedures 10

Sequential procedure 10

CPT “Separate procedure” definition 10

More extensive procedure 10

Gender-specific procedures 11

Standards of medical/surgical practice 11

Anesthesia service included in surgical procedure 11

Laboratory panel 11

Deleted/modified edits for NCCI 12

Misuse of column two code with column one code 12

General Correspondence Language for Medically Unlikely Edits (MUE)

(Units of Service)

Medically Unlikely Edits (MUE) (Units of Service) 12

Deleted/modified edits for MUE 13

Section-specific examples for Anesthesia Services

(CPT codes 00000 - 09999)

NCCI PTP edits 14-15

Medically Unlikely Edits (Units of Service) 15

Section-specific examples for Surgery: Integumentary System

(CPT Codes 10000 - 19999)

NCCI PTP edits 16-18

Medically Unlikely Edits (Units of Service) 18

Section-specific examples for Surgery: Musculoskeletal System

(CPT Codes 20000 - 29999)

NCCI PTP edits 19-21

Medically Unlikely Edits (Units of Service) 21

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Revision Date (Medicare): 4/1/2014

TABLE OF CONTENTS (Continued)

Section Page

Section-specific examples for Surgery: Respiratory, Cardiovascular,

Hemic and Lymphatic Systems (CPT Codes 30000 - 39999)

NCCI PTP edits 22-24

Medically Unlikely Edits (Units of Service) 24

Section-specific examples for Surgery: Digestive System

(CPT Codes 40000 - 49999)

NCCI PTP edits 25-27

Medically Unlikely Edits (Units of Service) 27

Section-specific examples for Surgery: Urinary, Male Genital,

Female Genital, Maternity Care and Delivery Systems

(CPT Codes 50000 - 59999)

NCCI PTP edits 28-30

Medically Unlikely Edits (Units of Service) 30

Section-specific examples for Surgery: Endocrine, Nervous, Eye

and Ocular Adnexa, Auditory Systems (CPT Codes 60000 - 69999)

NCCI PTP edits 31-32

Medically Unlikely Edits (Units of Service) 33

Section-specific examples for Radiology Services

(CPT Codes 70000 - 79999)

NCCI PTP edits 34-36

Medically Unlikely Edits (Units of Service) 36

Section-specific examples for Pathology and Laboratory Services

(CPT Codes 80000 - 89999)

NCCI PTP edits 37-38

Medically Unlikely Edits (Units of Service) 39

Section-specific examples for Medicine, Evaluation and Management Services

(CPT Codes 90000 - 99999)

NCCI PTP edits 40-42

Medically Unlikely Edits (Units of Service) 42

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Revision Date (Medicare): 4/1/2014

TABLE OF CONTENTS (Continued)

Section Page

Section-specific examples for CPT Category III Codes

(Temporary CPT Codes for Emerging Technology,

Services, and Procedures) (CPT Codes 0000T – 0999T)

NCCI PTP edits 43-45

Medically Unlikely Edits (Units of Service) 45

Section-specific examples for Supplemental Services

(HCPCS Level II Codes A0000 - V9999)

NCCI PTP edits 46-47

Medically Unlikely Edits (Units of Service) 48

Examples of Deleted National Correct Coding Initiative (NCCI) Edits

and Medically Unlikely Edits (MUE)

Deleted NCCI PTP Edit Example 49

Deleted MUE Example 49

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Revision Date (Medicare): 4/1/2014

Introduction

The Centers for Medicare and Medicaid Services (CMS) established the National

Correct Coding Initiative (NCCI) program to ensure the correct coding of services. The

NCCI program includes two types of edits: NCCI edits (also known as Procedure to

Procedure (PTP) edits) and Medically Unlikely Edits (MUEs) (Units of Service).

NCCI PTP edits prevent inappropriate payment of services that should not be reported

together. Each PTP edit has a column one and column two HCPCS/CPT code and a

Correct Coding Modifier Indicator (CCMI). If a provider reports the two codes of an edit

pair for the same beneficiary on the same date of service and the CCMI is 0, the column

two code is denied, and the column one code is eligible for payment. If the CCMI is 1

and if an NCCI-associated modifier is used because the appropriate clinical

circumstances are met, the NCCI PTP edit will be bypassed. If the CCMI is 1 and an

NCCI-associated modifier is not used, the column two code is denied.

Medically Unlikely Edits (MUEs) prevent payment for an inappropriate number/quantity

of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum

number of units of service (UOS) under most circumstances reportable by the same

provider for the same beneficiary on the same date of service.

Each NCCI PTP edit and each MUE has a corresponding Correspondence Language

Example Identification Number (CLEID). The CLEID provides information to Medicare

claims processing contractors about the rationale for these edits that can be used to

help educate providers about the edits. For example, a Medicare contractor may refer

to the CLEID when responding to an inquiry about a specific NCCI PTP edit or MUE or

to an appeal of a claim line that was denied due to an edit. The CLEID that

corresponds to each NCCI PTP edit is currently not included in the NCCI PTP edit files

that are posted on the CMS Medicare NCCI web site. That information is currently only

available to the Medicare contractors. The following information provides guidance to

providers when a CLEID is referenced in a response from a Medicare contractor.

The CLEID is formatted as follows: DD.EEEEEEEEE.

DD identifies the general policy that provides the rationale for the edit. There are

fourteen categories of general policies for NCCI PTP edits. They are:

1. Standard preparation/monitoring services for anesthesia

2. HCPCS/CPT procedure code definition

3. CPT Manual or CMS manual coding instruction

4. Mutually exclusive procedures

5. Sequential procedure

6. CPT “Separate procedure” definition

7. More extensive procedure

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Revision Date (Medicare): 4/1/2014

8. Reserved for future use

9. Gender-specific procedures

10. Standards of medical/surgical practice

11. Anesthesia service included in surgical procedure

12. Laboratory panel

13. Deleted/modified edits for NCCI

14. Misuse of column two code with column one code

There are two categories of general policies for MUEs. They are:

15. Medically Unlikely Edits (MUEs) (Units of Service)

16. Deleted/modified edits for MUE

Detailed information about each of the general policies can be found in individual

sections of Chapter I of the National Correct Coding Initiative Policy Manual for

Medicare Services which is posted on the CMS Medicare NCCI web site. The general

correspondence language relating to each of these policy categories is found on pages

9 – 13 of this Manual.

EEEEEEEEE identifies the section of this Manual to use for a specific example related

to the policy statement. For example, if EEEEEEEEE is 10000, the example refers to

column one CPT codes from the 10000 series of codes in the CPT Manual. For NCCI

PTP edits with a column one HCPCS code of A0000 – V9999, the entry for

EEEEEEEEE is “A – V” rather than a number.

When developing correspondence using the “Correspondence Language Manual",

Medicare claims processing contractors utilize two paragraphs from this Manual:

• The first paragraph is the relevant "General Correspondence Language"

statement as identified by DD. The column one and column two codes of the edit

pair in question are entered in appropriate spaces in that paragraph.

• The second paragraph is the relevant section-specific example as identified by

EEEEEEEEE.

For example, for the NCCI PTP edit with a column one code of 37760 and a column two

code of 15271, the CLEID is 2.30000. An individual providing an explanation of this edit

would use two paragraphs from the "Correspondence Language Manual". The first

paragraph would be the paragraph "2. HCPCS/CPT procedure code definition" from the

"General Correspondence Language" portion of this Manual (page 9). The second

paragraph would be selected from the "Section Specific Examples" for the 30000 series

of codes, “Respiratory, Cardiovascular, Hemic and Lymphatic Systems”. The

correspondent would select the example identified as "Correspondence Language

Policy/Example Number 2.30000" (page 22). The two paragraphs would be:

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Revision Date (Medicare): 4/1/2014

The HCPCS/CPT procedure code definition, or descriptor, is based upon

contemporary medical practice. When a HCPCS/CPT code is submitted to

Medicare, all services described by the descriptor should have been performed.

Because some HCPCS/CPT codes describe complex procedures with several

components which may under certain circumstances be performed

independently, some of the component procedures have their own HCPCS/CPT

codes. If a HCPCS/CPT code is reported along with other HCPCS/CPT codes

that are components of the descriptor of the first code, only the first code should

be reported. The HCPCS/CPT code 37760 descriptor includes the service

described by the descriptor of HCPCS/CPT code 15271. Thus, based upon the

HCPCS/CPT code descriptors HCPCS/CPT code 15271 is bundled into

HCPCS/CPT code 37760.

For example, the code descriptor for CPT code 33612 is “Repair of double outlet

right ventricle with intraventricular tunnel repair; with repair of right ventricular

outflow tract obstruction” and the code descriptor for CPT code 33611 is “Repair

of double outlet right ventricle with intraventricular tunnel repair;”. Therefore,

based upon the code descriptors the procedure described by CPT code 33611 is

a component of the procedure described by CPT code 33612, and CPT code

33611 is bundled into CPT code 33612.

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Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

General Correspondence Language

1. Standard preparation/monitoring services for anesthesia: Anesthesia

services require certain services to prepare a patient prior to the administration of

anesthesia and to monitor a patient during the course of anesthesia. Additionally, when

monitored anesthesia care (MAC) is provided, the attention devoted to patient

monitoring is of a similar level of intensity so that general anesthesia may be

established if needed. The specific services necessary to prepare and monitor a patient

vary among procedures based upon the extent of the surgical procedure, the type of

anesthesia (general, MAC, regional, local, etc.), and the surgical risk. The physician

determines which preparation and monitoring services are utilized for an anesthesia

procedure. These services are included in the anesthesia service. Accordingly, when

reporting the anesthesia service code, HCPCS/CPT code_____ (the column one

HCPCS/CPT code), the services described by HCPCS/CPT code ______ (the column

two HCPCS/CPT code) are included in the anesthesia service.

2. HCPCS/CPT procedure code definition: The HCPCS/CPT procedure code

definition, or descriptor, is based upon contemporary medical practice. When a

HCPCS/CPT code is submitted to Medicare, all services described by the descriptor

should have been performed. Because some HCPCS/CPT codes describe complex

procedures with several components which may under certain circumstances be

performed independently, some of the component procedures have their own

HCPCS/CPT codes. If a HCPCS/CPT code is reported along with other HCPCS/CPT

codes that are components of the descriptor of the first code, only the first code should

be reported. The HCPCS/CPT code ______ (the column one HCPCS/CPT code)

descriptor includes the service described by the descriptor of HCPCS/CPT code _____

(the column two HCPCS/CPT code). Thus, based upon the HCPCS/CPT code

descriptors, HCPCS/CPT code ______ (the column two HCPCS/CPT code) is bundled

into HCPCS/CPT code ______ (the column one HCPCS/CPT code).

3. CPT Manual or CMS manual coding instruction: In addition to CPT

procedure code definitions or descriptors, instructions in the CPT Manual are provided

either as an introduction to CPT sections or parenthetically. Additionally CMS issues

coding instructions and guidelines in its manuals, program memoranda, and other

publications. In the case of HCPCS/CPT code____ (the column one HCPCS/CPT

code) and HCPCS/CPT code_____ (the column two HCPCS/CPT code), CPT or CMS

instructions identify appropriate methodology for code submission and accordingly,

HCPCS/CPT code ______ (the column two HCPCS/CPT code) is included in or cannot

be reported with HCPCS/CPT code _____ (the column one HCPCS/CPT code).

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Revision Date (Medicare): 4/1/2014

4. Mutually exclusive procedures: In order to provide a sufficiently broad

listing of descriptive terms and identifying HCPCS/CPT codes, certain services or

procedures are listed which would not reasonably be performed at the same session by

the same provider on the same beneficiary. In the case of HCPCS/CPT

code______(the column one HCPCS/CPT code) and HCPCS/CPT code _____(the

column two HCPCS/CPT code), it would be unreasonable to expect these services to

be performed at a single patient encounter and, therefore, these HCPCS/CPT codes

have been paired together as edits.

5. Sequential procedure: If a provider attempts several procedures in direct

succession at a patient encounter to accomplish the same end, only the procedure that

successfully accomplishes the expected result is reported. Generally, this occurs when

a less extensive procedure fails and requires the performance of a more extensive

procedure. A failed procedure followed by a more extensive procedure should not be

reported separately. Procedures that are often performed in sequence have been

identified and the less extensive procedure is not separately reportable with the more

extensive procedure. When the procedures corresponding to HCPCS/CPT code____

(the column one HCPCS/CPT code) and HCPCS/CPT code _____ (the column two

HCPCS/CPT code) are performed in sequence at the same patient encounter, only

HCPCS/CPT code______ (the column one HCPCS/CPT code) may be reported.

6. CPT “Separate procedure” definition: The narrative for many HCPCS/CPT

codes includes a parenthetical statement that the procedure represents a "separate

procedure". The inclusion of this statement indicates that the procedure can be

performed separately but should not be reported when a related service is performed.

A “separate procedure” should not be reported when performed along with another

procedure in an anatomically related region through the same skin incision or orifice, or

surgical approach. HCPCS/CPT code____ (the column two HCPCS/CPT code) is

designated as a "separate procedure". Therefore, if it is reported with HCPCS/CPT

code______ (the column one HCPCS/CPT code), HCPCS/CPT code (the column

two HCPCS/CPT code) is bundled into HCPCS/CPT code_____ (the column one

HCPCS/CPT code).

7. More extensive procedure: Some procedures can be performed at varying

levels of complexity. The HCPCS/CPT codes corresponding to more extensive

procedures always include the HCPCS/CPT codes corresponding to less complex

procedures. HCPCS/CPT code _______ (the column one HCPCS/CPT code) is a more

extensive procedure that includes HCPCS/CPT code_______ (the column two

HCPCS/CPT code). Accordingly, only the more extensive procedure, HCPCS/CPT

code ______ (the column one HCPCS/CPT code) should be reported. HCPCS/CPT

code_____ (the column two HCPCS/CPT code) is bundled into HCPCS/CPT

code______ (the column one HCPCS/CPT code).

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Revision Date (Medicare): 4/1/2014

8. Reserved for Future Use

9. Gender-specific procedures: The performance of certain procedures may

require significantly different approaches when performed in a male as opposed to a

female. Some HCPCS/CPT code descriptors designate these procedures by specifying

if the service or procedure is to be reported for a male or a female or by anatomical

description. HCPCS/CPT code combinations that are identical, except that one code

describes a procedure for a female and the other describes a procedure for a male,

cannot be reported for the same session, the same provider, and the same beneficiary.

HCPCS/CPT codes _____ (the column one HCPCS/CPT code) and HCPCS/CPT

code_____(the column two HCPCS/CPT code) represent such a combination and

should not be reported together.

10. Standards of medical/surgical practice: Under Medicare, all services

necessary to complete a procedure based upon standard medical/surgical practice are

included in the procedure. Many procedures that are typically necessary to complete a

more comprehensive procedure have been assigned independent HCPCS/CPT codes

because they may be performed independently in other settings. The service described

by HCPCS/CPT code ____ (the column two HCPCS/CPT code) is typically included

when performing the procedure described by HCPCS/CPT code ____ (the column one

HCPCS/CPT code) and is therefore bundled into HCPCS/CPT code _____(the column

one HCPCS/CPT code.)

11. Anesthesia service included in surgical procedure: Pursuant to

Medicare’s Anesthesiology Rules, Medicare does not pay separately for anesthesia

other than moderate conscious sedation under certain circumstances when provided by

the same physician who performs the medical or surgical procedure requiring the

anesthesia. HCPCS/CPT codes describing anesthesia services or services that are

bundled into anesthesia services should not be reported in addition to the surgical

procedure requiring the anesthesia services. Accordingly, HCPCS/CPT code ____ (the

column two HCPCS/CPT code representing the anesthesia service or service bundled

into anesthesia) is included in the surgical service described by HCPCS/CPT code____

(the column HCPCS/CPT code).

12. Laboratory panel: Laboratory panels, described in CPT as "Organ or

Disease Oriented Panels,” define groupings of laboratory tests that are commonly

performed together in clinical practice. When a HCPCS/CPT code describing a panel is

reported, HCPCS/CPT codes identifying the individual tests included in the panel should

not be reported separately. HCPCS/CPT code____ (the column one HCPCS/CPT code

representing the laboratory panel) includes HCPCS/CPT code _____ (the column two

HCPCS/CPT code). Therefore HCPCS/CPT code____ (the column two HCPCS/CPT

code) is bundled into HCPCS/CPT code____ (the laboratory panel code or the column

one HCPCS/CPT code.)

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Revision Date (Medicare): 4/1/2014

13. Deleted/modified edits for NCCI: National Correct Coding Initiative (NCCI)

edits were developed based upon review of existing local and national edits, review of

standards of medical care, review of CPT instructions and descriptors, review of

provider billing patterns and Medicare policies. Comments about NCCI PTP edits are

received from the AMA and the national medical societies, representatives of the AMA’s

CPT Editorial Panel, CPT Advisory, and Health Care Professionals Advisory (HCPAC)

Committees, CMS Central and Regional Offices, Contractor Medical Directors,

contractor staff, physicians, other providers, and independent billing consultants. Based

upon input from these sources, NCCI PTP edits are sometimes deleted. NCCI PTP

edits may also be deleted for other reasons such as CMS policies, modified

HCPCS/CPT code descriptors or coding instructions, deletion of HCPCS/CPT codes, or

modified medical practice. (Occasionally the order of the codes in an edit needs to be

reversed. In such situations, the original edit is deleted and a new edit is added with the

order of the codes reversed.) The HCPCS/CPT code pair edit, HCPCS/CPT code

______ (the column one HCPCS/CPT code) and HCPCS/CPT code ______ (the

column two HCPCS/CPT code) was deleted from the NCCI for one of these reasons.

14. Misuse of column two code with column one code: HCPCS/CPT codes

have been written as precisely as possible to not only describe a specific procedure but

to also avoid describing similar procedures which are already defined by other

HCPCS/CPT codes. When a HCPCS/CPT code is reported, the physician or non-

physician provider must have performed all of the services noted in the descriptor

unless the descriptor states otherwise. (Occasionally, a HCPCS/CPT code descriptor

will identify certain services that may or may not be included.) A HCPCS/CPT code

should not be reported out of the context for which it was intended. When the

procedure described by HCPCS/CPT code _________ (the column two HCPCS/CPT

code) is reported with the procedure described by HCPCS/CPT code _______ (the

column one HCPCS/CPT code), reporting the former code represents a misuse of this

code, and separate payment is not allowed.

15. Medically Unlikely Edits (MUE) (Units of Service): Most HCPCS/CPT

codes describe procedures that may be reported a maximum number of times by a

single provider for the same beneficiary on the same date of service. If a provider bills

units of service for HCPCS/CPT codes in excess of established limits, the edits prevent

payment. The Medically Unlikely Edit values are set based upon anatomic

considerations, HCPCS/CPT code descriptors, HCPCS/CPT coding instructions, CMS

policies, nature of analyte, nature of service/procedure, nature of equipment, and/or

clinical judgment based on input from many sources. MUE values were reviewed by

national healthcare organizations before implementation. All MUE values have been

evaluated with 100% claims data from a six month period. CMS publishes most MUE

values. However, unpublished MUE values are confidential information for CMS and

CMS contractors’ use only. No information about unpublished MUE values shall be

released or shared outside your organization.

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Revision Date (Medicare): 4/1/2014

16. Deleted/modified edits for MUE: Medically Unlikely Edits (MUE) were

developed based upon anatomic considerations, HCPCS/CPT code descriptors,

HCPCS/CPT coding instructions, CMS policies, nature of service/procedure, nature of

analyte, nature of equipment, and/or clinical judgment. Prior to implementation most

MUE were reviewed by national healthcare organizations. Comments about MUE are

received from the AMA and the national medical societies, representatives of the AMA’s

CPT Editorial Panel, CPT Advisory, and Health Care Professionals Advisory (HCPAC)

Committees, CMS Central and Regional Offices, Medicare Contractor Medical

Directors, contractor staff, physicians, other providers, and independent billing

consultants. Based upon input from these sources, an MUE may be deleted. MUE may

also be deleted for other reasons such as CMS policies, modified HCPCS/CPT code

descriptors or coding instructions, deletion of HCPCS/CPT codes, or modified medical

practice. (Occasionally an MUE is modified. In such situations the original MUE is

deleted, and a new MUE with the revised MUE value is added). The MUE for the

HCPCS/CPT code ______ was deleted or modified for one of these reasons.

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National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Anesthesia Services

CPT Codes 00000-09999

Correspondence Language Policy/Example Number 1.00000 - Standard

preparation/monitoring services for anesthesia

An example of a “standard preparation/monitoring service” integral to anesthesia

services is the placement of an intravenous access line (CPT code 36000) prior to the

administration of general anesthesia. This procedure is necessary to prepare the

patient for a general anesthesia procedure and, therefore, is included as a part of the

anesthesia service. CPT code 36000 is bundled into all anesthesia service codes.

Correspondence Language Policy/Example Number 2.00000 – HCPCS/CPT

procedure code definition

For example, the descriptor for CPT code 99143 “(Moderate sedation services (other

than those services described by codes 00100-01999) provided by the same physician

performing the diagnostic or therapeutic service that the sedation supports, requiring the

presence of an independent trained observer to assist in the monitoring of the patient's

level of consciousness and physiological status; younger than 5 years of age, first 30

minutes intra-service time)” indicates that the code includes moderate conscious

sedation services other than those services described by anesthesia codes (00100-

01999). Therefore, CPT code 99143 should not be separately reported with anesthesia

codes such as CPT code 00100 “(Anesthesia for procedures on salivary glands,

including biopsy)”.

Correspondence Language Policy/Example Number 3.00000 - CPT Manual or CMS

manual coding instruction

For example, in the CPT Manual instruction under anesthesia for diagnostic

arteriography/venography (CPT code 01916), the reference note states: “(Do not report

01916 in conjunction with therapeutic codes 01924-01926, 01930-01933)”. Therefore,

CPT code 01916 is bundled with CPT codes 01924-01926 and 01930-01933.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 7.00000 – More extensive

procedure

For example, CPT code 01830 describes anesthesia for open or surgical

arthroscopic/endoscopic procedures on the wrist as well as other sites contiguous to the

wrist, and CPT code 01829 describes anesthesia for diagnostic arthroscopic procedures

on the wrist. Reporting CPT code 01829 with CPT code 01830 is not appropriate

because the procedure described by CPT code 01830 is more extensive than the

procedure described by CPT code 01829. In this case CPT code 01829 is bundled into

CPT code 01830.

Correspondence Language Policy/Example Number 14.00000 - Misuse of column

two code with column one code

For example, CPT code 95956 describes “Monitoring for localization of cerebral seizure

focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG)

recording and interpretation, each 24 hours”. When EEG monitoring is performed

during anesthesia for an intracranial procedure (CPT code 00210), reporting this

monitoring separately with CPT code 95956 is a misuse of CPT code 95956.

Intraoperative EEG monitoring is integral to anesthesia services for intracranial

procedures. Therefore CPT code 95956 is not reported separately with CPT code

00210.

Correspondence Language Policy/Example Number 15.00000 – Medically Unlikely

Edits (Units of Service)

For example, CPT code 01996 (“Daily hospital management of epidural or

subarachnoid continuous drug administration”) by definition includes management of

epidural or subarachnoid continuous drug administration for an entire day. This code

may be reported with only one unit of service for a single date of services. If units of

service in excess of one are reported, the MUE prevents payment.

Medically Unlikely Edits (Units of Service) do not apply to Anesthesia Services

(CPT codes 00100-01995).

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Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Integumentary System

CPT Codes 10000-19999

Correspondence Language Policy/Example Number 2.10000 – HCPCS/CPT

procedure code definition

For example, the code descriptor for CPT code 19302 is “Mastectomy, partial (eg,

lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary

lymphadenectomy”, and the code descriptor for CPT code 19301 is “Mastectomy, partial

(eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy);”. Therefore, based

upon the code descriptors the procedure described by CPT code 19301 is a component

of the procedure described by CPT code 19302, and CPT code 19301 is bundled into

CPT code 19302.

Correspondence Language Policy/Example Number 3.10000 - CPT Manual or CMS

manual coding instruction

For example, the CPT Manual instruction under “Excision - Benign Lesions”, states that

the excision includes simple closure. Therefore the procedure described by the column

one CPT code 11400 (“Excision, benign lesion including margins, except skin tag

(unless listed elsewhere), trunk, arms, or legs; excised diameter 0.5 cm or less”)

includes the procedure described by the column two CPT code 12001 (“Simple repair of

superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities

(including hands and feet); 2.5cm or less”). CPT code 12001 is bundled into CPT code

11400.

Correspondence Language Policy/Example Number 4.10000 - Mutually exclusive

procedures

For example, a physician performing a destruction of a malignant lesion of the arm by

laser surgery, electrosurgery, cryosurgery, chemosurgery, or surgical curettement (CPT

code 17260) would not also report an excision of the same malignant lesion of the arm

(CPT code 11600). Only one method of treatment of the malignant skin lesion would be

performed at a single patient encounter. Therefore, CPT codes 17260 and 11600 are

mutually exclusive of each other.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 5.10000 - Sequential

procedure

For example, CPT code 10021 describes a fine needle aspiration biopsy without

imaging guidance. CPT code 19101 describes an open incisional biopsy of the breast.

If a fine needle aspiration biopsy of a breast lesion is unsuccessful and the physician

sequentially performs an incisional biopsy of the same lesion at the same patient

encounter, only the successful open incisional biopsy may be reported. Therefore, CPT

code 10021 is not separately reportable with CPT code 19101.

Correspondence Language Policy/Example Number 6.10000 – CPT “separate

procedure” definition

For example, the code descriptor for CPT code 19100 (“Biopsy of breast; percutaneous,

needle core, not using imaging guidance (separate procedure)”) includes the “separate

procedure” designation. When an excision of a breast lesion (CPT code 19125) is

performed, the procedure described by CPT code 19100 does not meet the definition of

a “separate procedure” when performed on the same breast. Therefore, CPT code

19100 cannot be reported separately and is bundled into CPT code 19125 when both

services are performed on the same breast.

Correspondence Language Policy/Example Number 7.10000 - More extensive

procedure

For example, CPT code 19307 describes a modified radical mastectomy which removes

the entire breast and axillary adipose tissue. Although the primary purpose of a radical

mastectomy is generally the treatment of a malignant lesion, other lesions in the breast

such as cysts are also removed. Separate reporting of CPT code 19120 which

describes excision of benign breast lesions such as cysts is not appropriate with CPT

code 19307 for the same breast because the latter represents the more extensive

procedure. In this example CPT code 19120 is bundled into CPT code 19307.

Correspondence Language Policy/Example Number 10.10000 - Standards of

medical/surgical practice

For example, blepharoplasty of the upper eyelid (CPT code 15822) includes repair of

the incision (CPT code 12011) as a standard of medical/surgical practice. Therefore,

CPT code 12011 is bundled into CPT code 15822.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 11.10000 - Anesthesia

service included in surgical procedure

For example, when an avulsion of a nail plate (CPT code 11730) is performed,

anesthesia may be provided by the surgeon using a digital nerve block (CPT code

64450). Because this type of anesthesia provided by the surgeon performing the

procedure is not separately payable, CPT code 64450 is bundled into CPT code 11730

when the same physician performs both procedures.

Correspondence Language Policy/Example Number 14.10000 - Misuse of column

two code with column one code

For example, CPT code 11900 (Intralesional injection) describes a therapeutic

cutaneous intralesional injection. It is a misuse of this code to report it for the injection

of local anesthesia in order to perform another procedure such as an excision of a

benign skin lesion (CPT code 11400). Therefore, CPT code 11900 is bundled into CPT

code 11400.

Correspondence Language Policy/Example Number 15.10000 – Medically Unlikely

Edits (Units of Service)

For example, CPT code 11719 (Trimming of nondystrophic nails, any number) by

definition includes “any number” of nails. This code may be reported only once for a

patient on any single date of service by the same provider. If units of service in excess

of one are reported, the MUE prevents payment.

Page 19 of 49

Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Musculoskeletal System

CPT Codes 20000-29999

Correspondence Language Policy/Example Number 2.20000 - HCPCS/CPT

procedure code definition

For example, the code descriptor for CPT code 21045 is “Excision of malignant tumor of

mandible; radical resection”, and the code descriptor for CPT code 21044 is “Excision of

malignant tumor of mandible;”. Therefore based upon the code descriptors the

procedure described by CPT code 21044 is a component of the procedure described by

CPT code 21045, and CPT code 21044 is bundled into CPT code 21045.

Correspondence Language Policy/Example Number 3.20000 - CPT Manual or CMS

manual coding instruction

For example, the parenthetical note following CPT code 29889 states: “(Procedures

29888 and 29889 should not be used with reconstruction procedures 27427-27429)”.

Thus, CPT codes 29888 and 29889 are bundled into the more comprehensive

procedures reported as CPT codes 27427, 27428, and 27429.

Correspondence Language Policy/Example Number 4.20000 - Mutually exclusive

procedures

For example, CPT codes 27441 and 27442 describe different types of knee

arthroplasties of the tibial plateau. CPT code 27441 describes the procedure on the

tibial plateau with debridement and partial synovectomy and CPT code 27442 describes

the procedure on femoral condyles or the tibial plateau(s). Since both procedures

would not be performed on the same knee at the same patient encounter, the two

procedures are mutually exclusive of one another.

Correspondence Language Policy/Example Number 5.20000 - Sequential

procedure

For example, if an initial deep bone biopsy by needle or trocar (CPT code 20225) is

unsuccessful and is followed by an open biopsy (CPT code 20250) at the same patient

encounter, only CPT code 20250 may be reported. Therefore, CPT code 20225 is not

separately reportable with CPT code 20250.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 6.20000 – CPT “separate

procedure” definition

For example, the code descriptor for CPT code 29870 (“Arthroscopy, knee, diagnostic,

with or without synovial biopsy (separate procedure)”) includes the “separate procedure”

designation. When a diagnostic arthroscopy of the knee with major synovectomy in two

or more compartments (CPT code 29876) is performed, the procedure described by

CPT code 29870 on the same knee does not meet the definition of a “separate

procedure”. Therefore, CPT code 29870 cannot be reported separately and is bundled

into CPT code 29876 when both services are performed on the same knee.

Correspondence Language Policy/Example Number 7.20000 - More extensive

procedure

For example, CPT code 21012 describes excision of a subcutaneous soft tissue tumor

of the face or scalp that measures 2 cm or more. CPT code 21011 describes excision

of a subcutaneous soft tissue tumor of the face or scalp that measures less than 2 cm.

Since excision of a tumor greater than 2 cm or more (CPT code 21012) is more

extensive than excision of a tumor less than 2 cm (CPT code 21011) when performed at

the same anatomic site, CPT code 21011 is bundled into CPT code 21012.

Correspondence Language Policy/Example Number 10.20000 - Standards of

medical/surgical practice

For example, CPT code 25115 describes a radical excision of a bursa or synovia of the

wrist. It is standard surgical practice to preserve neurologic function by isolating and

freeing nerves as necessary. A neuroplasty (e.g. CPT code 64719) should not be

reported separately for this process. Therefore, CPT code 64719 is bundled into CPT

code 25115.

Correspondence Language Policy/Example Number 11.20000 - Anesthesia

service included in surgical procedure

For example, when a small joint or bursa arthrocentesis, aspiration and/or injection

(CPT code 20600) is performed, anesthesia may be provided by the surgeon using a

digital nerve block (CPT code 64450). Because this type of anesthesia provided by the

surgeon performing the procedure is not separately payable, CPT code 64450 is

bundled into CPT code 20600 when the same physician performs both procedures.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 14.20000 - Misuse of column

two code with column one code

For example, CPT code 20550 (“Injection(s); single tendon sheath, or ligament,

aponeurosis (eg, plantar “fascia”)”) describes a therapeutic musculoskeletal injection. It

is a misuse of this code to report it for the injection of local anesthesia in order to

perform another procedure such as a hallux valgus correction (CPT code 28292).

Therefore, CPT code 20550 is bundled into CPT code 28292.

Correspondence Language Policy/Example Number 15.20000 – Medically Unlikely

Edits (Units of Service)

For example, CPT code 27440 (Arthroplasty, knee, tibial plateau) may only be

performed on a knee once on a single date of service. If performed on a single knee,

this procedure would be reported with one unit of service. If this procedure is performed

bilaterally, it should be reported with modifier 50 and one unit of service. If units of

service in excess of one are reported, the MUE prevents payment.

Page 22 of 49

Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Respiratory System, Cardiovascular System,

Hemic and Lymphatic Systems, Mediastinum and Diaphragm

CPT Codes 30000-39999

Correspondence Language Policy/Example Number 2.30000 - HCPCS/CPT

procedure code definition

For example, the code descriptor for CPT code 33612 is “Repair of double outlet right

ventricle with intraventricular tunnel repair; with repair of right ventricular outflow tract

obstruction” and the code descriptor for CPT code 33611 is “Repair of double outlet

right ventricle with intraventricular tunnel repair;”. Therefore, based upon the code

descriptors the procedure described by CPT code 33611 is a component of the

procedure described by CPT code 33612, and CPT code 33611 is bundled into CPT

code 33612.

Correspondence Language Policy/Example Number 3.30000 - CPT Manual or CMS

manual coding instruction

For example, CPT code 33645 describes a direct or patch closure of the sinus venosus

with or without anomalous pulmonary venous drainage. The CPT Manual instruction

below CPT code 33645 states: “(Do not report 33645 in conjunction with 33724,

33726)”. Therefore, CPT code 33724 which describes a repair of isolated partial

anomalous pulmonary venous return may not be reported in addition to CPT code

33645.

Correspondence Language Policy/Example Number 4.30000 - Mutually exclusive

procedures

For example, CPT codes 33820 and 33822 describe different types of repairs of a

patent ductus arteriosus. CPT code 33820 describes a patent ductus arteriosus repair

by ligation, and CPT code 33822 describes a patent ductus arteriosus repair by division.

Since both procedures would not be performed on a patent ductus arteriosus at the

same patient encounter, the two procedures are mutually exclusive of one another.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 5.30000 - Sequential

procedure

For example, if a surgical endoscopic operative tissue ablation and reconstruction of

atria, limited (eg, modified maze procedure), without cardiopulmonary bypass (CPT

code 33265) is unsuccessful and is followed at the same patient encounter by an open

operative tissue ablation and reconstruction of atria, limited (eg, modified maze

procedure) (CPT code 33254), only CPT code 33254 may be reported. Therefore, CPT

code 33265 is not separately reportable with CPT code 33254.

Correspondence Language Policy/Example Number 6.30000 – CPT “separate

procedure” definition

For example, the code descriptor for CPT code 33210 (“Insertion or replacement of

temporary transvenous single chamber cardiac electrode or pacemaker catheter

(separate procedure)”) includes the “separate procedure” designation. When a

coronary artery bypass with single arterial graft procedure (CPT code 33533) is

performed, the procedure described by CPT code 33210 does not meet the definition of

a “separate procedure”. Therefore, CPT code 33210 cannot be reported separately and

is bundled into CPT code 33533.

Correspondence Language Policy/Example Number 7.30000 - More extensive

procedure

For example, CPT code 32663 describes thoracoscopy with lobectomy of a single lobe.

CPT code 32671 describes thoracoscopy with removal of the entire lung

(pneumonectomy). Since the right lung has three lobes and the left lung has two lobes,

a pneumonectomy (CPT code 32671) is a more extensive procedure than a lobectomy

(CPT code 32663). Therefore, CPT code 32663 is bundled into CPT code 32671.

Correspondence Language Policy/Example Number 10.30000 - Standards of

medical/surgical practice

For example, CPT code 32480 describes the removal of a single lobe of a lung. CPT

code 32100 describes a thoracotomy with exploration which is the surgical approach for

the procedure described by CPT code 32480 and is the standard of medical/surgical

practice. Therefore, CPT code 32100 is bundled into CPT code 32480.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 11.30000 - Anesthesia

service included in surgical procedure

For example, when direct operative laryngoscopy with foreign body removal is

performed (CPT code 31530) and anesthesia is also performed by the surgeon (CPT

code 00320), separate reporting for the anesthesia service is inappropriate. Therefore

CPT code 00320 is bundled into CPT code 31530.

Correspondence Language Policy/Example Number 14.30000 - Misuse of column

two code with column one code

For example, CPT code 35226 (“Repair blood vessel, direct; lower extremity”) describes

an open blood vessel repair of the lower extremity. It is a misuse of CPT code 35226 to

report it for the repair of the site where a percutaneous intra-aortic balloon assist device

is removed (CPT code 33968). Therefore CPT code 35226 is bundled into CPT code

33968.

Correspondence Language Policy/Example Number 15.30000 – Medically Unlikely

Edits (Units of Service)

For example, CPT code 33470 (Valvotomy, pulmonary valve, closed heart;

transventricular) may be reported with a maximum of one unit of service on a single

date of service since the heart has one pulmonary valve. If units of service in excess of

one are reported, the MUE prevents payment.

Page 25 of 49

Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Digestive System

CPT Codes 40000-49999

Correspondence Language Policy/Example Number 2.40000 - HCPCS/CPT

procedure code definition

For example, the code descriptor for CPT code 45805 is “Closure of rectovesical fistula;

with colostomy” and the code descriptor for CPT code 45800 is “Closure of rectovesical

fistula;”. Therefore, based upon the code descriptors the procedure described by CPT

code 45800 is a component of the procedure described by CPT code 45805, and CPT

code 45800 is bundled into CPT code 45805.

Correspondence Language Policy/Example Number 3.40000 - CPT Manual or CMS

manual coding instruction

For example, the CPT Manual instruction above CPT code 49491 states: “With the

exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other

prostheses is not separately reported.” Therefore, CPT code 49568 (mesh

implantation) should not be reported separately with CPT code 49505 (inguinal hernia

repair).

Correspondence Language Policy/Example Number 4.40000 - Mutually exclusive

procedures

For example, CPT codes 43100 and 43101 describe different approaches to the

excision of an esophageal lesion. CPT code 43100 describes a cervical approach, and

CPT code 43101 describes a thoracic or abdominal approach. Since both procedures

would not be performed at the same patient encounter, the two procedures are mutually

exclusive of one another.

Correspondence Language Policy/Example Number 5.40000 - Sequential

procedure

For example, if an anoscopy with control of bleeding (CPT code 46614) is unsuccessful

and is followed by a complex or an extensive internal and external hemorrhoidectomy

(CPT code 46260), only CPT code 46260 may be reported. Therefore, CPT code

46614 is not separately reportable with CPT code 46260.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 6.40000 – CPT “separate

procedure” definition

For example, the code descriptor for CPT code 44005 (“Enterolysis (freeing of intestinal

adhesion) (separate procedure)”) includes the “separate procedure” designation. When

a partial colectomy with anastomosis (CPT code 44140) is performed, the procedure

described by CPT code 44005 does not meet the definition of a “separate procedure”.

Therefore, CPT code 44005 cannot be reported separately and is bundled into CPT

code 44140.

Correspondence Language Policy/Example Number 7.40000 - More extensive

procedure

For example, CPT code 42426 describes excision of a parotid gland tumor with radical

neck dissection. CPT code 42425 describes excision of a parotid gland tumor without a

radical neck dissection. The procedure described by CPT code 42426 is more

extensive than the procedure described by CPT code 42425. Therefore, CPT code

42425 is bundled into CPT code 42426.

Correspondence Language Policy/Example Number 10.40000 - Standards of

medical/surgical practice

For example, during a tonsillectomy (CPT code 42821) bleeding may occur. The

control of such bleeding intraoperatively is a standard of surgical practice. It is

inappropriate to report separately CPT code 42961 (control of oropharyngeal

hemorrhage). Therefore, CPT code 42961 is bundled into CPT code 42821.

Correspondence Language Policy/Example Number 11.40000 - Anesthesia

service included in surgical procedure

For example, if an ilioinguinal or iliohypogastric nerve block (CPT code 64425) is

performed for anesthesia by the physician performing an inguinal hernia repair (CPT

code 49505), the nerve block is included in the surgical procedure and is not reported

separately. Therefore, CPT code 64425 is bundled into CPT code 49505.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 14.40000 - Misuse of column

two code with column one code

For example, CPT code 44378 describes small intestinal endoscopy with control of

bleeding. CPT code 44361 describes small intestinal endoscopy with biopsy. It is a

misuse of CPT code 44378 to report control of bleeding resulting from a small intestinal

biopsy. A small intestinal biopsy is often accompanied by a small amount of bleeding,

the control of which is inherent to the procedure and is not separately reportable.

Therefore, CPT code 44378 is bundled into CPT code 44361. CPT code 44378 should

not be reported separately unless it is performed as a distinct procedure unrelated to

bleeding due to the biopsy.

Correspondence Language Policy/Example Number 15.40000 – Medically Unlikely

Edits (Units of Service)

For example, CPT code 44950 (Appendectomy) may be reported with a maximum of

one unit of service since there is only one appendix. If units of service in excess of one

are reported, the MUE prevents payment.

Page 28 of 49

Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Urinary System, Male Genital System, Intersex Surgery,

Female Genital System, Maternity Care and Delivery

CPT Codes 50000-59999

Correspondence Language Policy/Example Number 2.50000 - HCPCS/CPT

procedure code definition

For example, the code descriptor for CPT code 51925 is “Closure of vesicouterine

fistula; with hysterectomy”, and the code descriptor for CPT code 51920 is “Closure of

vesicouterine fistula;”. Therefore, based upon the code descriptors the procedure

described by CPT code 51920 is a component of the procedure described by CPT code

51925, and CPT code 51920 is bundled into CPT code 51925.

Correspondence Language Policy/Example Number 3.50000 - CPT Manual or CMS

manual coding instruction

For example, the parenthetical note following CPT code 58146 states: “(Do not report

58146 in addition to 58140-58145, 58150-58240)”. Therefore, CPT code 58146 is not

separately reportable with CPT code 58150.

Correspondence Language Policy/Example Number 4.50000 - Mutually exclusive

procedures

For example, CPT codes 50800 and 50860 describe different types of ureteral diversion

procedures. CPT code 50800 describes diversion to the intestine, and CPT code 50860

describes diversion to the skin (ureterostomy). Since both procedures would not be

performed on the same ureter at the same patient encounter, the two procedures are

mutually exclusive of one another.

Correspondence Language Policy/Example Number 5.50000 - Sequential

procedure

For example, if a needle or punch biopsy of the prostate by any approach (CPT code

55700) is unsuccessful and is followed at the same patient encounter by an incisional

biopsy of the prostate (CPT code 55705), only CPT code 55705 may be reported.

Therefore, CPT code 55700 is bundled into CPT code 55705.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 6.50000 – CPT “separate

procedure” definition

For example, the code descriptor for CPT code 49000 (“Exploratory laparotomy,

exploratory celiotomy with or without biopsy(s) (separate procedure)”) includes the

“separate procedure” designation. When a total abdominal hysterectomy, with or

without removal of tubes and/or ovaries (CPT code 58150) is performed, the procedure

described by CPT code 49000 does not meet the definition of a “separate procedure”.

Therefore, CPT code 49000 cannot be reported separately and is bundled into CPT

code 58150.

Correspondence Language Policy/Example Number 7.50000 - More extensive

procedure

For example, CPT code 54530 describes a radical orchiectomy through an inguinal

approach. Since a partial orchiectomy (CPT code 54522) removes a smaller portion of

the testis, the procedure described by CPT code 54530 is more extensive than the one

described by CPT code 54522. Therefore, CPT code 54522 is bundled into CPT code

54530.

Correspondence Language Policy/Example Number 9.50000 - Gender-specific

procedures

For example, CPT code 52270 describes a cystourethroscopy with an internal

urethrotomy for a female, and CPT code 52275 describes the identical procedure for a

male. The two procedures cannot be reported for the same beneficiary. Therefore only

the appropriate code should be reported.

Correspondence Language Policy/Example Number 10.50000 - Standards of

medical/surgical practice

For example, CPT code 51820 describes a cystourethroplasty with unilateral or bilateral

ureteroneocystostomy. CPT code 51701 describes an insertion of a non-dwelling

bladder catheter and may be performed as a standard of medical/surgical practice prior

to performing a cystourethroplasty with ureteroneocystostomy (CPT code 51820).

Therefore, CPT code 51701 is bundled into CPT code 51820.

Correspondence Language Policy/Example Number 11.50000 - Anesthesia

service included in surgical procedure

For example, when an incision and drainage of a Bartholin’s gland abscess (CPT code

56420) is performed and anesthesia is also performed by the surgeon (CPT code

00940), separate reporting for the anesthesia service is inappropriate. Therefore, CPT

code 00940 (anesthesia for vaginal procedures) is bundled into CPT code 56420.

Page 30 of 49

Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 14.50000 - Misuse of column

two code with column one code

For example, an incidental appendectomy during another intra-abdominal surgical

procedure should not be reported separately. It is a misuse of CPT code 44950

(“Appendectomy”) to report it for an incidental appendectomy during the procedure

described by CPT code 58150 (Total abdominal hysterectomy, with or without removal

of tube(s), with or without removal of ovary(s)). Therefore, CPT code 44950 is bundled

into CPT code 58150.

Correspondence Language Policy/Example Number 15.50000 – Medically Unlikely

Edits (Units of Service)

For example, CPT code 55840 (Prostatectomy, retropubic radical, with or without nerve

sparing) may be reported with a maximum of one unit of service because there is only

one prostate gland in males. If units of service in excess of one are reported, the MUE

prevents payment.

Page 31 of 49

Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Endocrine System, Nervous System, Eye and Ocular Adnexa,

Auditory System, Operating Microscope

CPT Codes 60000-69999

Correspondence Language Policy/Example Number 2.60000 - HCPCS/CPT

procedure code definition

For example, the code descriptor for CPT code 67039 is “Vitrectomy, mechanical, pars

plana approach; with focal endolaser photocoagulation” and the code descriptor for CPT

code 67036 is “Vitrectomy, mechanical, pars plana approach;”. Therefore, based upon

the code descriptors the procedure described by CPT code 67036 is a component of

the procedure described by CPT code 67039, and CPT code 67036 is bundled into CPT

code 67039.

Correspondence Language Policy/Example Number 3.60000 - CPT Manual or CMS

manual coding instruction

For example, CPT code 66711 describes a ciliary body destruction with endoscopic

cyclophotocoagulation. The CPT Manual instruction following CPT code 66711 states:

“(Do not report 66711 in conjunction with 66990)”. Therefore, CPT code 66990 for use

of ophthalmic endoscope is bundled into CPT code 66711.

Correspondence Language Policy/Example Number 4.60000 - Mutually exclusive

procedures

For example, CPT codes 69433 and 69436 describe different types of tympanostomy

requiring insertion of ventilating tube. CPT code 69433 describes the procedure

performed with local or topical anesthesia, and CPT code 69436 describes the

procedure performed with general anesthesia. Since both procedures would not be

performed at the same patient encounter, the two procedures are mutually exclusive of

one another.

Correspondence Language Policy/Example Number 5.60000 - Sequential

procedure

For example, if a fine needle aspiration of the thyroid (CPT code 10021) is unsuccessful

and is followed at the same patient encounter by a percutaneous core needle biopsy of

the thyroid (CPT code 60100), only CPT code 60100 may be reported. Therefore, CPT

code 10021 is not separately reportable with CPT code 60100.

Page 32 of 49

Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 6.60000 – CPT “separate

procedure” definition

For example, the code descriptor for CPT code 65860 (“Severing adhesions of anterior

segment, laser technique (separate procedure)”) includes the “separate procedure”

designation. When a trabeculoplasty by laser surgery (CPT code 65855) is performed,

the procedure described by CPT code 65860 does not meet the definition of a “separate

procedure”. Therefore, CPT code 65860 cannot be reported separately and is bundled

into CPT code 65855.

Correspondence Language Policy/Example Number 7.60000 - More extensive

procedure

For example, CPT code 67228 describes destruction of extensive diabetic retinopathy

by photocoagulation. CPT code 67208 describes destruction of a localized retinal

lesion by cryotherapy. The procedure described by CPT code 67228 is more extensive

than the procedure described by CPT code 67208. Therefore, CPT code 67208 is

bundled into CPT code 67228.

Correspondence Language Policy/Example Number 10.60000 - Standards of

medical/surgical practice

For example, CPT code 60240 describes a total or complete thyroidectomy. CPT code

60500 describes a parathyroidectomy or exploration of parathyroid(s).

The exploration of parathyroid glands with or without parathyroidectomy (CPT code

60500) is standard surgical practice when performing a complete thyroidectomy (CPT

code 60240). Therefore, CPT code 60500 is bundled into CPT code 60240.

Correspondence Language Policy/Example Number 11.60000 - Anesthesia

service included in surgical procedure

For example, if the surgeon performing a cataract extraction (CPT code 66984) also

provides anesthesia (CPT code 00142), the anesthesia service is not reported

separately. Therefore, CPT code 00142 is bundled into CPT code 66984.

Correspondence Language Policy/Example Number 14.60000 - Misuse of column

two code with column one code

For example, CPT code 20550 (“Injection(s); single tendon sheath, or ligament,

aponeurosis (eg, plantar “fascia”)”) describes a therapeutic musculoskeletal injection. It

is a misuse of this code to report it for the injection of local anesthesia in order to

perform another procedure such as a carpal tunnel release (CPT code 64721).

Therefore, CPT code 20550 is bundled into CPT code 64721.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 15.60000 – Medically Unlikely

Edits (Units of Service)

For example, CPT code 62292 (Injection procedure for chemonucleolysis, including

discography, intervertebral disc, single or multiple levels, lumbar) by definition includes

treatment at “single or multiple levels” of the lumbar spine. If units of service in excess

of one are reported, the MUE prevents payment.

Page 34 of 49

Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Radiology Services

CPT Codes 70000-79999

Correspondence Language Policy/Example Number 2.70000 - HCPCS/CPT

procedure code definition

For example, the code descriptor for CPT code 71270 is “Computed tomography,

thorax; without contrast material, followed by contrast material(s) and further sections”

and the code descriptor for CPT code 71260 is “Computed tomography, thorax; with

contrast material(s)”. Therefore, based upon the code descriptors the procedure

described by CPT code 71260 is a component of the procedure described by CPT code

71270, and CPT code 71260 is bundled into CPT code 71270.

Correspondence Language Policy/Example Number 3.70000 - CPT Manual or CMS

manual coding instruction

For example, CPT code 70332 describes radiological supervision and interpretation of a

temporomandibular joint arthrogram. The CPT Manual instruction following CPT code

70332 states: “(Do not report 70332 in conjunction with 77002).” Therefore, CPT code

77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection,

localization device)) is bundled into CPT code 70332.

Correspondence Language Policy/Example Number 4.70000 - Mutually exclusive

procedures

For example, CPT codes 74240 and 74245 describe radiologic examination of the

upper gastrointestinal tract. CPT code 74245 also includes radiologic examination of

the small intestine which CPT code 74240 does not. Since both procedures could not

be performed at the same patient encounter, the two procedures are mutually exclusive

of one another.

Page 35 of 49

Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 6.70000 – CPT “separate

procedure” definition

For example, the code descriptor for CPT code 76000 (“Fluoroscopy (separate

procedure), up to one hour physician time, other than 71023 or 71034 (eg, cardiac

fluoroscopy)”) includes the “separate procedure” designation. When radiological

supervision and interpretation (RS&I) for percutaneous transhepatic biliary drainage

with contrast monitoring (CPT code 75980) is performed, the procedure described by

CPT code 76000 does not meet the definition of a “separate procedure”. Therefore,

CPT code 76000 cannot be reported separately and is bundled into CPT code 75980.

Correspondence Language Policy/Example Number 7.70000 - More extensive

procedure

For example, CPT code 72240 describes radiologic supervision and interpretation

(RS&I) for cervical myelography. CPT code 72270 describes RS&I for myelography of

two or more spinal regions (i.e. cervical/thoracic region, lumbar/thoracic region,

lumbar/cervical region). If the myelography RS&I performed includes two or more

spinal regions, one of which is the cervical region, the procedure described by CPT

code 72270 is more extensive than the one described by CPT code 72240. Therefore,

CPT code 72240 is bundled into CPT code 72270.

Correspondence Language Policy/Example Number 10.70000 - Standards of

medical/surgical practice

For example, CPT code 74170 describes an abdominal CT scan requiring intravenous

administration of contrast. Since intravenous insertion of a catheter (CPT code 36000)

is a standard medical/surgical practice to infuse the contrast, CPT code 36000 is

bundled into CPT code 74170.

Correspondence Language Policy/Example Number 11.70000 - Anesthesia

service included in surgical procedure

For example, if the physician performing magnetic resonance imaging of the cervical

spinal canal without contrast material (CPT code 72141) also provides anesthesia for

the non-invasive imaging (CPT code 01922), the anesthesia service is not reported

separately. Therefore, CPT code 01922 is bundled into CPT code 72141.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 14.70000 - Misuse of column

two code with column one code

For example, CPT code 75945 describes intravascular ultrasound of a non-coronary

vessel. CPT code 76998 describes intraoperative ultrasound guidance. It is a misuse

of CPT code 76998 to report it for intraoperative ultrasound guidance to perform

intravascular ultrasound of a non-coronary vessel. Therefore, CPT code 76998 is

bundled into CPT code 75945.

Correspondence Language Policy/Example Number 15.70000 – Medically Unlikely

Edits (Units of Service)

For example, CPT code 77080 (Dual-energy X-ray absorptiometry (DXA), bone density

study, 1 or more sites; axial skeleton . . .) may be reported with a maximum of one unit

of service because the code descriptor includes all axial skeletal sites and the test

would only be performed once on a single date of service. If units of service in excess of

one are reported, the MUE prevents payment.

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Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Pathology and Laboratory Services

CPT Codes 80000-89999

Correspondence Language Policy/Example Number 2.80000 - HCPCS/CPT

procedure code definition

For example, the code descriptor for CPT code 80192 is “Procainamide; with

metabolites (eg, n-acetyl procainamide)” and the code descriptor for CPT code 80190 is

“Procainamide; ”. Therefore, based upon the code descriptors the procedure described

by CPT code 80190 is a component of the procedure described by CPT code 80192,

and CPT code 80190 is bundled into CPT code 80192.

Correspondence Language Policy/Example Number 3.80000 - CPT Manual or CMS

manual coding instruction

For example, CPT codes 86920 and 86923 describe different types of blood

compatibility testing. The CPT Manual instruction following CPT code 86923 states:

“(Do not use 86923 in conjunction with 86920-86922 for same unit crossmatch)”.

Therefore, CPT code 86923 cannot be reported with CPT codes 86920, 86921 and/or

86922 for compatibility testing of the same unit of blood.

Correspondence Language Policy/Example Number 4.80000 - Mutually exclusive

procedures

For example, CPT codes 81000 and 81001 describe different ways of performing

urinalysis with microscopy. The procedure described by CPT code 81000 utilizes a

manual process with dip stick or tablet reagent, and the procedure described by CPT

code 81001 utilizes an automated process. Since both procedures would not be

performed on the same urine specimen at the same patient encounter, the two

procedures are mutually exclusive of one another.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 7.80000 - More extensive

procedure

For example, CPT code 80500 describes a clinical pathology consultation and CPT

code 80502 describes a clinical pathology consultation with review of patient history and

medical records. The procedure described by CPT code 80502 is more extensive than

the procedure described by CPT code 80500 because it requires additional review of

patient history and medical records. Therefore, CPT code 80500 is bundled into CPT

code 80502.

Correspondence Language Policy/Example Number 10.80000 - Standards of

medical/surgical practice

For example, CPT code 82575 describes creatinine clearance, and CPT code 82565

describes blood creatinine. Since determination of creatinine clearance (CPT code

82575) requires measurement of the blood creatinine (CPT code 82565) in addition to

urine creatinine and 24-hour urine volume, the measurement of blood creatinine is

included in the creatinine clearance as a standard of medical/surgical practice.

Therefore, CPT code 82565 is bundled into CPT code 82575.

Correspondence Language Policy/Example Number 12.80000 - Laboratory panel

For example, CPT code 80076 describes a hepatic function panel which includes seven

specific laboratory tests. If all seven individual tests are performed at the same patient

encounter, the hepatic function panel (CPT code 80076) may be reported. If one or

more of the seven specific laboratory tests such as serum albumin (CPT code 82040) is

additionally reported, it represents duplicate reporting of the laboratory test. Therefore,

CPT code 82040 is bundled into CPT code 80076 when performed on the same

specimen.

Correspondence Language Policy/Example Number 14.80000 - Misuse of column

two code with column one code

For example, the professional component CPT code 88141 describes the physician

interpretation of a diagnostic cervical or vaginal cytopathology specimen and may be

reported with technical component CPT codes for diagnostic cervical or vaginal

cytopathology such as CPT codes 88142-88154, 88164-88167, and 88174-88175. CPT

code 88141 should not be reported with HCPCS codes for screening cervical or vaginal

cytopathology such as G0143. It is a misuse of CPT code 88141 to report a physician

interpretation of a screening cervical or vaginal cytopathology specimen reported as

HCPCS code G0143.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 15.80000 – Medically Unlikely

Edits (Units of Service)

For example, CPT code 83036 describes a test for Hemoglobin A1C (glycosylated

hemoglobin). Since this analyte is a measure of blood glucose control over the prior

three months, it would be measured at most once on a single date of service. If units of

service in excess of one are reported, the MUE prevents payment.

Page 40 of 49

Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

Medicine Services

CPT Code 90000-99999

Correspondence Language Policy/Example Number 2.90000 - HCPCS/CPT

procedure code definition

For example, the code descriptor for CPT code 96406 is “Chemotherapy administration;

intralesional, more than 7 lesions”, and the code descriptor for CPT code 96405 is

“Chemotherapy administration; intralesional, up to and including 7 lesions”. Based upon

the code descriptors the procedure described by CPT code 96405 cannot be reported

with CPT code 96406 since either more than 7 or 7 or fewer lesions are treated.

Therefore, CPT code 96405 is bundled into CPT code 96406.

Correspondence Language Policy/Example Number 3.90000 - CPT Manual or CMS

manual coding instruction

For example, the CPT Manual instruction above CPT code 96150 states: “Do

not report 96150-96155 in conjunction with 90785-90899 on the same date.”

Therefore, CPT codes 96150-96155 (Health and behavior assessment and intervention)

may not be reported separately with CPT code 90791 (Psychiatric diagnostic

evaluation) and CPT codes 96150-96155 are bundled into CPT codes 90785-90899.

Correspondence Language Policy/Example Number 4.90000 - Mutually exclusive

procedures

For example, CPT codes 95953 and 95956 describe different types of EEG monitoring

for localization of cerebral seizure focus. CPT code 95953 describes monitoring by

computerized portable electroencephalography (16 or more channel EEG), and CPT

code 95956 describes monitoring by cable or radio, 16 or more channel telemetry.

Since both methods of EEG monitoring would not be utilized in the same 24-hour

period, the two procedures are mutually exclusive of one another.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 6.90000 – CPT “separate

procedure” definition

For example, the code descriptor for CPT code 95851 (range of motion measurements

and report (separate procedure); each extremity . . .) includes the "separate procedure"

designation. When a physical therapy evaluation (CPT code 97001) is performed, the

procedure described by CPT code 95851 does not meet the definition of a “separate

procedure”. Therefore, CPT code 95851 cannot be reported separately and is bundled

into CPT code 97001.

Correspondence Language Policy/Example Number 7.90000 - More extensive

procedure

For example, CPT code 93010 describes the physician interpretation of an

electrocardiogram (ECG). CPT code 93042 describes the physician interpretation of a

cardiac rhythm strip. Since the ECG interpretation described by CPT code 93010

includes an interpretation of cardiac rhythm abnormalities, the procedure described by

CPT code 93010 is more extensive than the procedure described by CPT code 93042.

Therefore, CPT code 93042 is bundled into CPT code 93010.

Correspondence Language Policy/Example Number 10.90000 - Standards of

medical/surgical practice

For example, fluorescein angiography (CPT code 92235) requires the intravenous

administration of fluorescein. Since intravenous insertion of a catheter (CPT code

36000) is a standard of medical/surgical practice to infuse the fluorescein, CPT code

36000 is bundled into CPT code 92235.

Correspondence Language Policy/Example Number 11.90000 - Anesthesia

service included in surgical procedure

For example, when an induction of arrhythmia by electrical pacing (CPT code 93618) is

performed, anesthesia may be provided by the physician performing the procedure as

described by CPT code 00410 (anesthesia for the electrical conversion of arrhythmias).

Because anesthesia provided by the physician performing the procedure is not

separately payable, CPT code 00410 is bundled into CPT code 93618 when the same

physician performs both procedures.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 14.90000 - Misuse of column

two code with column one code

For example, CPT code 96912 describes photochemotherapy with psoralens and

ultraviolet A light (PUVA). CPT code 77401 describes delivery of superficial radiation

therapy. It is a misuse of CPT code 77401 to report it in addition to CPT code 96912

when PUVA therapy is administered. Therefore CPT code 77401 ((radiation treatment

delivery) is bundled into CPT code 96912 (photochemotherapy).

Correspondence Language Policy/Example Number 15.90000 – Medically Unlikely

Edits (Units of Service)

For example, CPT code 94002 describes all ventilation assist and management for the

initial day of observation or inpatient hospital care. Therefore, CPT code 94002 may be

reported with a maximum of one unit of service for a single date of service. If units of

service in excess of one are reported, the MUE prevents payment.

Page 43 of 49

Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

CPT Category III Codes (0001T-0999T)

(Temporary CPT Codes for Emerging Technology,

Services, and Procedures)

Correspondence Language Policy/Example Number 2.0000T – HCPCS/CPT

procedure code definition

For example, the code descriptor for CPT code 0178T is “Electrocardiogram, 64 leads

or greater, with graphic presentation and analysis; with interpretation and report”, and

the code descriptor for CPT code 0180T is “Electrocardiogram, 64 leads or greater, with

graphic presentation and analysis; interpretation and report only”. Therefore, based

upon the code descriptors the procedure described by CPT code 0180T is a component

of the procedure described by CPT code 0178T, and CPT code 0180T is bundled into

CPT code 0178T.

Correspondence Language Policy/Example Number 3.0000T - CPT Manual or CMS

manual coding instruction

For example, the parenthetical note after CPT code 0073T states: “(Do not report 0073T

in conjunction with 77401-77416, 77418).” Therefore, CPT code 77401 cannot be

reported separately in addition to CPT code 0073T, and CPT code 77401 is bundled

into CPT code 0073T.

Correspondence Language Policy/Example Number 4.0000T - Mutually exclusive

procedures

For example, CPT codes 0101T and 0102T describe extracorporeal shock wave

procedures involving different anatomic parts of the musculoskeletal system. CPT code

0101T describes extracorporeal shock wave involving an unspecified part of the

musculoskeletal system and CPT code 0102T describes extracorporeal shock wave

involving the lateral humeral epicondyle. Since both extracorporeal shock wave

procedure codes should not be reported for the same patient at the same anatomic site,

the two procedures are mutually exclusive of one another.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 6.0000T – CPT “separate

procedure” definition

For example, the code descriptor for CPT code 49000 (“Exploratory laparotomy,

exploratory celiotomy with or without biopsy(s) (separate procedure)”) includes the

“separate procedure” designation. When a transluminal peripheral atherectomy of the

abdominal aorta (CPT code 0236T) is performed, the procedure described by CPT code

49000 does not meet the definition of a “separate procedure”. Therefore, CPT code

49000 cannot be reported separately and is bundled into CPT code 0236T.

Correspondence Language Policy/Example Number 7.0000T – More extensive

procedure

For example, CPT code 0072T describes focused ultrasound ablation of uterine

leiomyomata of a volume greater than or equal to 200 cc of tissue. CPT code 0071T

describes focused ultrasound ablation of uterine leiomyomata of a volume less than 200

cc of tissue. Since CPT code 0072T is a more extensive procedure than CPT code

0071T, CPT code 0071T is bundled into CPT code 0072T.

Correspondence Language Policy/Example Number 10.0000T - Standards of

medical/surgical practice

For example, CPT code 0075T describes percutaneous transcatheter placement of

extracranial vertebral or intrathoracic carotid artery stent(s). Since intravenous insertion

of a catheter (CPT code 36000) is a standard of medical/surgical practice for this

procedure, CPT code 36000 is bundled into CPT code 0075T.

Correspondence Language Policy/Example Number 11.0000T - Anesthesia

service included in surgical procedure

For example, if the physician performing a transluminal peripheral atherectomy, open or

percutaneous, including radiological supervision and interpretation of the abdominal

aorta (CPT code 0236T) also provides anesthesia for the procedure, the anesthesia

service is not separately reported. Therefore, CPT code 01926 (“Anesthesia for

therapeutic interventional radiological procedures involving the arterial system;

intracranial, intracardiac, or aortic”) is bundled into CPT code 0236T.

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Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 14.0000T - Misuse of column

two code with column one code

For example, CPT code 0051T describes implantation of a total replacement heart

system (artificial heart) with recipient cardiectomy. CPT code 39010 describes a

mediastinotomy for exploration, drainage, removal of foreign body, or biopsy by a

transthoracic approach. It is a misuse of CPT code 39010 to report a mediastinotomy

for the surgical approach to perform the procedure coded as CPT code 0051T.

Therefore, CPT code 39010 should not be reported with CPT code 0051T.

Correspondence Language Policy/Example Number 15.0000T – Medically Unlikely

Edits (Units of Service)

For example, CPT code 0181T (Corneal hysteresis determination, by air impulse

stimulation, bilateral, with interpretation and report) may be reported with a maximum of

one unit of service since the code descriptor indicates that it is a bilateral procedure. If

units of service in excess of one are reported, the MUE prevents payment.

Page 46 of 49

Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Section-specific Examples

HCPCS Level II Codes A0000-V9999

Correspondence Language Policy/Example Number 2.A-V - HCPCS/CPT

procedure code definition

For example, the code descriptor for HCPCS code G0398 is “Home sleep study test

(HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG,

EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation”, and the code

descriptor for CPT code 93041 is “Rhythm ECG, 1-3 leads; tracing only without

interpretation and report”. Based upon the code descriptors an ECG is a component of

the home sleep study test. Therefore, CPT code 93041 is bundled into HCPCS code

G0398.

Correspondence Language Policy/Example Number 3.A-V - CPT Manual or CMS

manual coding instruction

For example, the CPT Manual instruction above CPT code 49320 states: “Surgical

laparoscopy always includes diagnostic laparoscopy. . .” Therefore the surgical

laparoscopic procedure described by the column one HCPCS code G0342

(Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion)

includes the diagnostic laparoscopic procedure described by the column two CPT code

49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without

collection of specimen(s) by brushing or washing (separate procedure)). Based on the

CPT Manual instruction CPT code 49320 is bundled into HCPCS code G0342.

Correspondence Language Policy/Example Number 4.A-V - Mutually exclusive

procedures

For example, HCPCS code G0105 describes colorectal cancer screening by

colonoscopy, and HCPCS code G0120 describes such screening by barium enema.

Since both methods would not be performed at the same patient encounter, the two

procedures are mutually exclusive of one another.

Page 47 of 49

Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 6.A-V – CPT “separate

procedure” definition

For example, the code descriptor for CPT code 49000 (“Exploratory laparotomy,

exploratory celiotomy with or without biopsy(s) (separate procedure)”) includes the

“separate procedure” designation. When a laparotomy for islet cell transplantation

(HCPCS code G0343) is performed, the procedure described by CPT code 49000 does

not meet the definition of a “separate procedure”. Therefore, CPT code 49000 may not

be reported separately and is bundled into HCPCS code G0343.

Correspondence Language Policy/Example Number 7.A-V - More extensive

procedure

For example, HCPCS code G0117 describes glaucoma screening performed by an

ophthalmologist or optometrist. HCPCS code G0118 describes glaucoma screening

performed under the direct supervision of an ophthalmologist or optometrist. Since

personal performance of a procedure is more extensive than direct supervision of a

procedure, HCPCS code G0118 is bundled into HCPCS code G0117.

Correspondence Language Policy/Example Number 10.A-V - Standards of

medical/surgical practice

For example, colorectal cancer screening using a barium enema radiologic study as an

alternative to screening by colonoscopy (HCPCS code G0120) includes as a standard

of medical/surgical practice all fluoroscopy (CPT code 76000) necessary to perform the

procedure. Therefore, CPT code 76000 is bundled into HCPCS code G0120.

Correspondence Language Policy/Example Number 11.A-V - Anesthesia service

included in surgical procedure

For example, if the physician performing a bone marrow aspiration with bone marrow

biopsy through the same incision on the same date of service (HCPCS code G0364)

also provides anesthesia for the procedure, the anesthesia service is not separately

reportable. Therefore CPT code 01112 (anesthesia for bone marrow aspiration and/or

biopsy) is bundled into HCPCS code G0364.

Correspondence Language Policy/Example Number 14.A-V - Misuse of column

two code with column one code

HCPCS code G0259 describes an injection procedure for arthrography of the sacroiliac

joint. CPT code 27096 describes an injection procedure of an anesthetic/steroid for

arthrography of the sacroiliac joint. It is a misuse of CPT code 27096 to report it with

HCPCS code G0259 for a procedure on the same sacroiliac joint at the same patient

encounter.

Page 48 of 49

Revision Date (Medicare): 4/1/2014

Correspondence Language Policy/Example Number 15.A-V – Medically Unlikely

Edits (Units of Service)

For example, since HCPCS code G0121 (Colorectal cancer screening; colonoscopy on

individual not meeting criteria for high risk) can only be performed once every ten years,

a maximum of one unit of service may be reported for a single date of service. If units

of service in excess of one are reported, the MUE prevents payment.

Page 49 of 49

Revision Date (Medicare): 4/1/2014

National Correct Coding Initiative’s

Correspondence Language

Examples of Deleted National Correct Coding Initiative (NCCI) PTP Edits

and Medically Unlikely Edits (MUE)

Correspondence Language Policy/Example Number 13.DELETEPR4 - Deleted

NCCI PTP Edit Example

For example, the edit with column one CPT code 93621 and column two CPT code

93620 was deleted because the 2002 CPT Manual added a reference note following

CPT code 93621 which stated: “(Use 93621 in conjunction with 93620)”. Therefore,

based upon new CPT Manual coding instructions, the edit was deleted.

Correspondence Language Policy/Example Number 16.DELETEPR5 – Deleted

MUE Example

For example, the MUE criterion for CPT code 49200 (excision or destruction, open,

intra-abdominal or retroperitoneal tumors or cysts or endometriomas) was implemented

as “1” on January 1, 2007. Since this code was deleted from the CPT Manual on

January 1, 2008, the MUE for the code was deleted December 31, 2007.

CORRECT CODING INITIATIVE’S 81001 Ncci Correspondence Language Manual

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