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Medicare's National Correct Coding Initiative (CCI) Edits

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative to promote national correct coding methodologies and to eliminate improper coding. CCI edits are developed based on coding conventions defined in the American Medical Association's Current Procedural Terminology (CPT) Manual, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practice.

This website is aimed at providing information to providers on Medicare's National CCI edits, but will not address specific CCI edits. If you have concerns regarding specific CCI edits, please submit your comments in writing to:

National Correct Coding Initiative
AdminaStar Federal, Inc.
P.O. Box 50469
Indianapolis, IN 46250-0469

Site Content:

Helpful Questions and Answers

• How To Obtain a Copy of the CCI Policy and Edits Manual
• Terms and Definitions That Apply to CCI
• Correct Coding Principles and Edits
• CCI Modifiers
• How To Obtain Assistance With Questions Related to CCI Edits
• CCI and OCE Edits

Links to Applicable Program Memoranda Related to CCI

Links to Additional Program Memoranda on CCI Related to the Hospital Outpatient Prospective Payment System

CCI Versions

CCI edits are updated on a quarterly basis. Note that the CCI edits in the OCE are always one quarter behind.

How To Obtain a Copy of the CCI Policy and Edits Manual

Q1. How do I obtain the CCI Edits Manual?

A1. The CCI Edits Manual may be obtained in two ways. The first is through the CMS website at http://www.cms.hhs.gov/physicians/cciedits/default.asp. The CMS website contains a listing of the CCI edits, by specific CPT sections, and is available free for downloading to the public.

Secondly, the CCI Edits Manual may be obtained by purchasing the manual, or sections of the manual, from the National Technical Information Service (NTIS) website at http://www.ntis.gov/products/families/cci, or by contacting NTIS at 1-800-363-2068 or 703-605-6060. You may purchase an electronic version of the CCI Edits Manual from NTIS. Please contact NTIS for further information on the electronic version of the CCI edits. (8/21/03)

Q2. Before I purchase the manual, I would like to receive more information on it. Can I contact NTIS for more information on the CCI Edits Manual?

A2. Yes. To receive information on the CCI Edits Manual by fax, call 703-605-6880. (12/12/01)

Q3. Why do I have to purchase the CCI edits from NTIS instead of just receiving the information from my Carrier or FI?

A3. The volume of edits in each version update is too large to be produced by the Medicare Carriers or Fiscal Intermediaries (FIs) through a Medicare bulletin. Therefore, the CCI edits must be downloaded from the CMS website or purchased from NTIS. Please note that CPT-4 codes used in the CCI edits are copyrighted by the American Medical Association. (8/21/03)

Q4. Are the edits in the CCI Edits Manual valid for a whole year?

A4. No. The edits are updated on a quarterly basis. However, the NCCI Policy Manual is updated annually in October. (1/10/03)

Q5. There are some software coding programs that already contain the CCI edits. Do I still need to purchase the manual from NTIS?

A5. At this time the official method for providers to receive the CCI edits is through the CMS website or through NTIS. It is up to the hospital and to the physician to be aware of the quarterly updates to the CCI Edits Manual. (8/8/03)

Q6. If I have a question about or problem with the quality and format of the NTIS products, who should I contact?

A6. Contact the NTIS Sales Desk at 1-800-553-6847. (12/12/01)

Q7. Since my practice does not use all the codes in the HCPCS/CPT manuals, can I obtain only the edits that pertain to my specialty?

A7. Yes. The edits are organized by ranges of the column 1 codes into specific chapters (eg., 00000-09999, 10000-19999, 20000-29999, etc.). You may either download the specific section applicable to your physician's practice, or purchase single chapters that are applicable to your physician's practice. (8/21/03)

Q8. Is there a list of deletions to each version update available or do I have to do a comparison between the previous and the current version updates to determine which ones were actually deleted?

A8. The electronic file that is available on the CMS website has several columns, which include the effective dates and the deletion dates of the CCI edits. However, the CCI Manual (specifically the printed version) that is available from NTIS does not list the effective and deletion dates of the CCI edits. (8/8/03)

Q9. How are the CCI edits arranged in the manual?

A9. The edits are arranged by two sets of tables. One table contains the column 1/column 2 correct coding edits (formerly known as comprehensive/component edits), and the other contains the mutually exclusive edits. Each table is arranged in two columns, as represented below. Note that the column 2 codes in both tables are not payable with the column 1 codes unless the edit permits the use of a modifier associated with CCI.

Effective with version 9.3 of the CCI edits, the heading "Comprehensive/Component Edits" has been changed to the heading "Column 1/Column 2 Correct Coding Edits". The Column 1 code was previously termed represents the "comprehensive" code edits, and the Column 2 code was previously termed represents the "component" code edits. As many of you know, the table containing comprehensive/component edits also includes edits which do not involve a comprehensive/component relationship but are codes that should simply not be reported together for other reasons (e.g., "misuse of the code", etc). The headings have been changed to more accurately reflect the overall category of the edits within the tables and to eliminate the confusion as the result of using the term(s) "comprehensive/component." (8/21/03)

Column 1/Column 2 Correct Coding Edits (formerly Comprehensive/Component)		Mutually Exclusive Edits
Column 1	Column 2	Column 1	Column 2

Q10. If I want to determine what codes/procedures are paired with a certain code, how can I find this out?

A10. NTIS provides the printed versions of column 1/column 2 correct coding edits and mutually exclusive code edits sorted/sequenced in two ways - by column 1 code and by column 2 code. If a single code is found in both sorts, then you should have all the current code combinations active in the CCI with this certain code in either the column 1 or column 2 position. The NTIS electronic version allows you to search for a code in the database in either position.

CMS provides the electronic version of column 1/column 2 correct coding edits and the mutually exclusive code edits. Both tables are sorted by column 1 and column 2 edits. (8/8/03)

Q11. If I receive a denial for a procedure bundled into another service, and I cannot find this code pair in the column 1/column 2 correct coding list of edits, where else should I look?

A11. Look in the mutually exclusive code list. The mutually exclusive code edits in the printed version of the CCI Edits Manual are in the same chapter but separate from the column 1/ column 2 correct coding edits. The electronic version of the mutually exclusive code edits that is available on the CMS website can be found in a separate listing at http://www.cms.hhs.gov/physicians/cciedits/default.asp, which are arranged by specific chapters. (8/21/03)

Terms and Definitions That Apply to CCI

Q1. What are CCI edits?

A1. CCI edits are pairs of CPT or HCPCS Level II codes that are not separately payable except under certain circumstances. The edits are applied to services billed by the same provider for the same beneficiary on the same date of service. All claims are processed against the CCI tables. (8/21/03)

Q2. What does it mean when codes are considered "mutually exclusive" of each other?

A2. "Mutually exclusive" codes represent procedures or services that could not reasonably be performed at the same session by the same provider on the same beneficiary. (8/21/03)

Q3. What exactly does "column 1" mean in the column 1/column 2 correct coding edits table and in the mutually exclusive edits table?

A3. Formerly known as the "comprehensive code" within the column 1/column 2 correct coding edits table, the column 1 code generally represents the major procedure or service when reported with the column 2 code. When reported with the column 2 code, "column 1" generally represents the code with the greater work RVU of the two codes.

However, within the mutually exclusive edits table, "column 1" code generally represents the procedure or service with the lower work RVU, and is the payable procedure or service when reported with the column 2 code. (8/21/03)

Q4. What does "column 2" mean in the column 1/column correct coding edits table and in the mutually exclusive edits table?

A4. Formerly known as the "component code" within the column 1/column 2 correct coding edits table, this code represents the lesser procedure or service when reported with the column 1 code. When reported with the column 1 code, the "column 2" code generally represents the code with the lower work RVU of the two codes.

However, within the mutually exclusive edits table, the "column 2" code generally represents the procedure or service with the higher work RVU, and is the non-payable procedure or service when reported with the column 1 code. (8/21/03)

Q5. Why are there two CCI tables?

A5. To represent the mutually exclusive and column 1/column 2 correct coding edit tables. (8/21/03)

Q6. What is the mutually exclusive edit table?

A6. The mutually exclusive edit table contains edits consisting of two codes (procedures) which cannot reasonably be performed together based on the code definitions or anatomic considerations. Each edit consists of a column 1 and column 2 code. If the two codes of an edit are billed by the same provider for the same beneficiary for the same date of service without an appropriate modifier, the column 1 code is paid. If clinical circumstances justify appending a CCI-associated modifier to the column 2 code of a code pair edit, payment of both codes may be allowed (see section entitled "CCI Modifiers"). (8/21/03)

Q7. What is the column 1/column 2 correct coding edit table?

A7. The column 1/column 2 correct coding edit table contains two types of code pair edits. One type contains a column 2 (component) code which is an integral part of the column 1 (comprehensive) code. The other type contains code pairs that should not be reported together where one code is assigned as the column 1 code and the other code is assigned as the column 2 code. If two codes of a code pair edit are billed by the same provider for the same beneficiary for the same date of service without an appropriate modifier, the column 1 code is paid. If clinical circumstances justify appending a CCI-associated modifier to the column 2 code of a code pair edit, payment of both codes may be allowed (see section entitled "CCI Modifiers"). (8/21/03)

Correct Coding Principles and Edits

Q1. Where can I find information about the principles utilized to develop edits and examples of edits?

A1. The Correct Coding Policy Manual includes policy narratives that describe the principles utilized to develop edits and also provides examples. This manual is available from the National Technical Information Service (NTIS) at 1-800-363-2068 or 703-605-6060 and through the CMS website at http://www.cms.hhs.gov/physicians/cciedits/default.asp. (8/21/03)

Q2. How often are the CCI edits updated?

A2. The CCI edits are usually updated on a quarterly basis. Note that the CCI edits are included in the Outpatient Code Editor (OCE). Under the hospital OPPS, the CCI edits are always one version behind. (1/10/03)

Q3. Specifically, what does the effective date mean for CCI edits?

A3. This date applies to the dates of service on or after a given date. For example, version 8.0 of the CCI edits becomes effective January 01, 2002 for physician services. This means that the new edits to the NCCI for version 8.0 will apply to those claims with dates of service on or after January 1, 2002; however, the NCCI edits continued from previous version updates will be applied to claims with dates of service based on the original effective dates of those edits. (8/21/03)

Q4. Do I need to obtain each version update of the CCI in order to manage our coding practices effectively and efficiently?

A4. Yes, there are a varying number of changes in every update. The volume depends on the number of comments processed, the number of edits reviewed, and/or the number of focused efforts for edit development. (12/12/01)

Q5. Do the edits change that much between quarterly updates?

A5. The number of changes depend on the volume of comments received, modifications processed and edits reviewed. (12/12/01)

Q6. Why do the mutually exclusive procedures appear to be in the wrong order, that is, it seems the procedure with the higher payment is generally bundled into the service with the lower payment?

A6. Although the same action takes place in the Carrier claims processing systems on both the column 1/column 2 correct coding and the mutually exclusive code edits, which is that the column 1 code is payable and the column 2 code is not payable, the mutually exclusive code edits are set up so that the procedure with the lower work relative value unit is generally listed in the column 1 position as the payable service. This stems from the basic definition of mutually exclusive procedures which states that both these procedures could not reasonably be performed at the same patient encounter. It is expected that one or the other of a mutually exclusive code pair should be reported but not both. Therefore, for the mutually exclusive edits only, to promote correct coding and to deter providers from reporting codes improperly, CMS decided at CCI implementation on January 1, 1996 that the payable code should, in general, be the procedure with the lesser work RVU, which often results in the lower payment between the two services. (8/21/03)

Q7. If each of the procedures listed in a CCI edit is performed by two different physicians in my clinic of different specialties, will both services be paid?

A7. From a CCI perspective both will be considered for payment because the criteria that must be met for the bundling to occur is that the services are provided for the same beneficiary/patient, on the same date of service, by the same performing provider. However, there may be other national or local carrier/FI policies in place that would not allow both physicians from the same group to be paid in certain situations. (1/10/03)

Q8. Where can I find information about CCI in the Medicare manuals?

A8. Information about CCI can be found in Section 4630 of the Medicare Carrier Manual. (12/12/01)

Q9. What are some of the possible denial messages that may be displayed on the beneficiary's EOMB/MSN?

A9. They are as follows (12/12/01):

1. "Medicare does not pay for this service because it is part of another service that was performed at the same time."
2. "Payment is included in another service received on the same day."

CCI Modifiers

Q1. What modifiers are allowed with the CCI edits?

A1. The following modifiers are allowed with the CCI edits. (8/8/03)

Q2. Can these modifiers that are associated with the CCI be used with all the column 1/column 2 correct coding and mutually exclusive code edits?

A2. No, there are some column 1/column 2 correct coding and mutually exclusive code edits which CMS does not think would ever warrant the use of any of the modifiers associated with the CCI. These code pairs are assigned a correct coding modifier indicator of "0" which means that the modifiers associated with the CCI are not allowed. There is no situation in which the providers could justify the payment for both procedures based on separate patient encounters or different anatomic sites. (8/21/03)

Q3. If I determine that one of these modifiers is appropriate and should be used to describe the services I am reporting, to which code do I attach it?

A3. The procedure that is bundled (the column 2 code) would require additional information provided by the use of the modifier to explain the circumstance where both services should be paid. Providers are responsible for applying the correct modifiers appropriately to support the codes they report. Inappropriate use of modifiers not justified by the clinical circumstances constitutes fraud. (8/8/03)

Q4. Do I need to append a correct coding modifier to a procedure of a code pair edit if two different physicians performed each of the procedures or if the services were provided on different days?

A4. No. Either different dates of service or different rendering physicians do not meet the criteria for bundling. (12/12/01)

Q5. In what instances can I use the modifier -59 to designate a separate, different site?

A5. If none of the anatomical modifiers can be used appropriately to describe the different site, then the modifier -59 can be attached to indicate the separate location. (12/12/01)

Q6. What modifiers can be used to distinguish separate patient encounters on the same day?

A6. The global surgery modifiers are -25, -58, -78, and -79. If none of the previously mentioned modifiers applies, then modifier -59 can be used to indicate a separate session or patient encounter. (8/21/03)

Q7. How should modifier "-25" be reported under the CCI?

A7. Modifier "-25" should be appended to an evaluation and management (E/M) code when reported with another procedure on the same day of service. Appending modifier -25 to the E/M code indicates to the carriers or fiscal intermediaries that as a result of the patient's condition, the physician performed a significant, separately identifiable E/M service above and beyond the other service provided. (12/12/01)

Q8. How should modifier -59 be reported under the CCI?

A8. Modifier -59 is used to indicate a distinct procedural service. To appropriately report this modifier, append modifier -59 to the column 2 code to indicate that the procedure or service was independent from other services performed on the same day. The addition of this modifier indicates to the carriers or fiscal intermediaries that the procedure or service represents a distinct procedure or service from others billed on the same date of service. In other words, this may represent a different session, different anatomical site or organ system, separate incision/excision, different lesion, or different injury or area of injury (in extensive injuries). When used with a CCI edit, modifier -59 indicates that the procedures are different surgeries when performed at different operative areas or at different patient encounters. (1/10/03)

Q9. How should modifier -91 be reported under CCI?

A9. Modifier -91 should be appended to laboratory procedure(s) or service(s) to indicate a repeat test or procedure on the same day. This modifier indicates to the carriers or fiscal intermediaries that the physician had to perform a repeat clinical diagnostic laboratory test that was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain medically necessary subsequent reportable test values. This modifier should not be used to report repeat laboratory testing due to laboratory errors, quality control, or confirmation of results. (12/12/01)

Q10. Do the Medicare Carriers/FIs have different uses or guidelines for the application of the modifiers than the AMA?

A10. In some instances, the use and interpretation of the modifiers is different, even though the description of them is the same. (12/12/01)

Q11. In the manuals purchased from NTIS, what do the superscript numbers 0, 1 and 9 mean next to the CPT/HCPCS Level II codes?

A11. Each code pair (column 1/column 2 correct coding edits and mutually exclusive code edits) is assigned a correct coding modifier indicator of either a "0", "1", or "9". The "0" indicator means that no modifiers associated with the CCI are allowed to be used with this code pair; there are no circumstances in which both procedures of the code pair should be paid. The "1" indicator means that the modifiers associated with the CCI are allowed with this code pair when appropriate. The "9" indicator is used only on those code pairs that have been deleted where the deletion date was retroactive to the effective date. For all practical purposes, providers can ignore the "9" indicator.

These indicators of 0, 1 and 9 can also be found in the electronic version of the CCI edits provided by CMS under the column titled "Modifier."(8/21/03)

How To Obtain Assistance With Questions Related to CCI Edits

Q1. If I disagree with a procedure being bundled, who addresses my concerns/issues?

A1. AdminaStar Federal, Inc. (a subcontractor of Reliance Safeguard Solutions) develops and refines the National Correct Coding Initiative, coordinates the receipt of comments, the prioritization of issues, the review and research of previous actions, and the discussion with CMS about the concerns. ASF accepts written comments by fax at (317) 841-4600 or by mail. Their address is indicated below. (12/12/01)

National Correct Coding Initiative
AdminaStar Federal, Inc.
P.O. Box 50469
Indianapolis, IN 46250-0469
Attention to: Niles R. Rosen, MD or Linda Dietz, RHIA, CCS, CCS-P

Q2. What should I send to the NCCI for justification of my proposed modification to the edits?

A2. At a minimum the comment letter needs to include the HCPCS/CPT codes and descriptors in question and the justification for the proposed change (eg. clinical medical literature, studies, standards of medical practice, national medical policy, National Specialty Society/Association coding guidelines, AMA's coding instructions in CPT itself or AMA's coding advice as referenced in the CPT Assistant.) (12/12/01)

Q3. How long does it take to review a comment?

A3. We make every effort to respond to almost all comments within six weeks of receipt. (12/12/01)

Q4. Why does it sometimes appear that CMS adds edits to the CCI in one version, and then in the next version changes or deletes those edits?

A4. Changes in the CCI are the result of comments submitted to CMS via AdminaStar Federal, Inc. and CMS's written or telephone correspondence. Sometimes, new information is provided by a commenter which was not available previously. The ability of CMS to add, delete, and modify edits quarterly enables CCI to be responsive to the provider community. (12/12/01)

Q5. Does anyone have input about these edits before they are implemented?

A5. Edit modifications resulting from comments are often referred to medical societies prior to final disposition of the edit. In addition, the AMA receives a listing of all changes at least one month prior to the quarterly implementation of a new version of the CCI.

Also, each year a large edit package is developed based on changes to CPT/HCPCS Level II manuals (code/instruction, additions, deletions, and revisions). Edits from this package (including any and all edits where claims data shows that both codes in the proposed edit were reported together one or more times) are sent to the CMD Correct Coding Workgroup and to the AMA which disseminates them to the national (or medical) societies. Comments from CMDs, national societies, and the AMA are considered by CMS before implementation of these edits. (12/12/01)

Q6. Who facilitates the distribution of this yearly package of proposed edits (based on CPT/HCPCS Level II changes) to the National Medical/Surgical Societies for notice and comment?

A6. The American Medical Association coordinates the notice and comment process on behalf of the National Societies by distributing the proposed edits/modifications to the physician and non-physician groups. (1/10/03)

Q7. If I have received a response from ASF which states that CMS has decided not to change the edit about which I complained, is there any other recourse to produce a change?

A7. We frequently encourage the commenters to contact the appropriate national organization for guidance when this happens. The commenters may also research the issues further in order to provide new and necessary rationale to support their position. (12/12/01)

Q8. If I have a situation where I think one of the modifiers associated with the CCI should be used, is there someone who can tell me if I am using the modifier properly?

A8. Contact the provider relations department at your local Medicare Carrier/FI, present the scenario and ask the question preferably in writing. (12/12/01)

Q9. If I have individual claims to appeal, should I send these to my local Medicare Carrier or FI and request a review?

A9. AdminaStar Federal, Inc. has no authority nor access to act on individual claims. You must request an appeal from your local Medicare Carrier/FI. (12/12/01)

Q10. If I disagree with the payment on a procedure, to whom do I inquire?

A10. Contact the provider relations department at your local Medicare Carrier/FI for verification that the payment is correct. There are many national and local coverage and payment policies other than CCI which may affect payment for a service. (12/12/01)

Q11. If I receive a bundling message that says something is included in a service billed on the same day and I do not find evidence of this edit in the latest version update of CCI, who should I ask about this denial?

A11. Contact the provider relations department at your local Medicare Carrier/FI about other edits that may be in place on a national or local level which have nothing to do with the CCI edits. (12/12/01)

Q12. If I have received a denial on a procedure that was bundled and I notice that the procedure is no longer bundled in the latest version of the CCI edits, can I resubmit or appeal this denial?

A12. Yes, you may resubmit the claim with the denied service. Generally, deletions in CCI edits are retroactive. (12/12/01)

CCI and OCE Edits

Q1. What's the difference between the Outpatient Code Editor edits and the CCI edits?

A1. The OCE edits and the CCI edits are two editing systems used to process fiscal intermediary (hospital outpatient) and carrier-related claims, respectively. The CCI edits are developed based on coding conventions defined in the AMA's CPT Manual, current standards of medical and surgical coding practice, input from specialty societies, and based on analysis of current coding practice. The CCI edits are used for carrier processing of physician services under the Medicare Physician Fee Schedule while the OCE edits are used by intermediaries for processing hospital outpatient services under the Hospital OPPS.

The OCE is used in processing OPPS claims. Within the OCE are over 50 OCE edits, which determine whether a specific code is payable under the hospital OPPS. Many of the CCI edits are included in the OCE edits (see edit #19, 20, 39, and 40 below). The OCE edits are used exclusively under the hospital OPPS - they are not used within the Medicare Physician Fee Schedule.

The CCI edits always consist of pairs of HCPCS codes, and are arranged in two tables. One is the column 1/column 2 correct coding edits table, and the other is known as the mutually exclusive edits table. The OCE edits are arranged in numerical order with descriptions for each edit, as well as a claim disposition for each edit. Examples of OCE edits are listed below. For further information on the latest OCE edits within the hospital OPPS, please visit our website at http://cms.hhs.gov/manuals/memos/comm_date_dsc.asp to find the latest transmittal (program memorandum) on the OCE. (8/21/03)

Q2. Are all the CCI edits incorporated into the OCE?

A2. All CCI edits are incorporated in the OCE with exception of the following: anesthesiology edits, E&M, mental health, and dermabond. (12/12/01)

Q3. How often are the OCE edits updated?

A3. The OCE, including the OCE edits, is updated on a quarterly basis. (12/12/01)

Q4. Who can I contact for questions on issues related to the OCE edits?

A4. For questions on specific OCE edits, please contact the Division of Outpatient Care (DOC) within CMS at 410-786-0378. (12/12/01)

Q5. Specifically, which modifiers are recognized and accepted by the OCE?

A5. All level I and level II modifiers are accepted as valid in the OCE. However, only a subset of valid modifiers are used in OCE editing. Below is a listing of all the modifiers that are used in OCE editing. (4/16/04)