Coding per NCCI guidelines

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

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The National Correct Coding Initiative (NCCI) is a set of Medicare guidelines developed and implemented for the purpose of ensuring optimal Medicare-approved coding and billing for medical services. Many private insurers also follow the NCCI edicts. The NCCI consists of three principal components, all of which are available on the Web: the National Correct Coding Initiative Policy Manual for Medicare Services, the NCCI Code Pair Edits, and the Medically Unlikely Edits. Each of these facets of the NCCI contains information that is essential for proper Medicare billing and reimbursement. The Policy Manual explicitly describes various Medicare billing requirements and restrictions, including the uses and limitations of Current Procedural Terminology (CPT) modifiers. The Code Pair Edits is a list of paired CPT codes that determines whether both of two paired CPT codes are potentially payable if an appropriate modifier is used, and which of the two codes should receive the modifier. The Medically Unlikely Edits (MUEs) is a list of the usual maximally allowable units of service for a single CPT code billed for a single patient encounter. A reader-friendly explanation of the NCCI is available at

The following are several case scenarios with billing explanations based upon the NCCI guidelines.

Case 1: Your Medicare patient has a broad suspected lentigo maligna on her face. In order to assess for histologic variability within the lesion you biopsy, separately identify, and submit in separate containers for histopathologic evaluation three sites: superior, middle, and inferior. Do you bill for three separate biopsies, 11100 and 11101x2, or is your billing limited to one biopsy charge?

Answer: The National Correct Coding Initiative Policy Manual for Medicare Services (available at specifies that a single lesion biopsied multiple times may only be billed as one biopsy charge: “If a single lesion is biopsied multiple times, only one biopsy code may be reported with a single unit of service.” The appropriate charge for the above scenario is 11100, nothing more. [pagebreak]

Case 2: You have received for histopathologic interpretation three separately identified and processed specimens from the suspected lentigo maligna in Case 1. Three separate blocks, three separate tissue slides, and three separate interpretations and diagnoses are generated. Do you bill as you would for the biopsy, with one charge, or are you entitled to seek reimbursement for the three separate interpretations?

Answer: The NCCI document reads: “If it is medically reasonable and necessary to submit multiple biopsies of the same or different lesions for separate pathologic examination, the medical record must identify the precise location and separate nature of each biopsy.” Conclusion: you may bill for three separate 88305 or 88305-26 pathology charges. However, as the biopsies are all from the same location, they may, depending upon your diagnostic interpretation, all receive an identical ICD-9 diagnosis. Your claim for the second and third lesion interpretations, based upon a recent CMS missive, is then likely to be rejected as a duplicate; see

What now? The NCCI indicates that the interpretations beyond the first should be billed with modifier 91, “repeat clinical diagnostic test”. Thus, for three specimens the billing may be: 88305, 88305-91 and 88305-91 or 88305-26, 88305-26-91 and 88305-26-91. In the “Notes” section of the CMS1500 form it is helpful to specify the distinct locations of each biopsy. Individual Medicare contractors and private insurers may handle this situation in their own peculiar fashion. Some insurers will not recognize modifier 91 and automatically reject any such claim and may pay it only following a written appeal. Check with your local carriers to familiarize yourself with their policy. [pagebreak]

Case 3: You remove two facial nevi tangentially for cosmetic reasons. You ink one specimen and submit both in one container for histopathologic evaluation. Does one then bill for two 88305 interpretations, as there are two specimens being evaluated, or one, because both specimens are processed in one block and presented together on a slide?

Answer: The NCCI clarifies this by stating: “If multiple lesions are submitted for pathological examination as a single specimen, only one CPT code may be reported for examination of all the lesions even if each lesion is processed separately.” Consequently, appropriate billing is one 88305 or 88305-26 charge.

Case 4: A patient comes to you for evaluation of a skin tumor treatment. He brings along a copy of a pathology report and the original slides for your review. You evaluate the patient and interpret the biopsy slide tissue. You bill 99203 for the initial patient visit along with 88321, “consultation and report on referred slides prepared elsewhere.” Is that correct?

Answer: That is incorrect. The NCCI states: “CPT codes 88321-88325 should not be reported with a face-to-face evaluation of a patient. If a physician provides an evaluation and management (E/M) service to a patient, and, in the course of the E/M service, specimens obtained elsewhere are reviewed as well, this review is part of the E/M’s medical decision making service and is not reported separately. Only the E/M service should be reported.” You may only bill the 99203 E/M service. [pagebreak]

Case 5: You excise a large, abscessed epidermoid cyst from the back of a Medicare patient. Seven days later the patient returns with a fluctuant, liquefied hematoma, which you aspirate. Do you charge for CPT 10160, puncture aspiration of hematoma?

Answer: No charge is warranted. The hematoma and its in-office treatment occurred during the 10 day global period for the minor excision surgical procedure. The NCCI states: “…the global surgical package includes all medical and surgical services required of the surgeon during the postoperative period of the surgery to treat complications that do not require return to the operating room. Control of postoperative hemorrhage is also not separately reportable unless the patient must be returned to the operating room for treatment.” Check with your carriers to familiarize yourself with their policy on billing for complications.

Case 6: You schedule a new patient traveling a long distance for possible Mohs surgical excision of a basal cell carcinoma located on the nose. After evaluating the patient, examining the nose along with sun-damaged skin elsewhere, you determine appropriateness for Mohs surgery. You excise the tumor with one stage of Mohs surgery and repair the defect with an advancement flap. Since you performed an initial patient evaluation, determined the need for surgery, and then did the surgery, may you bill and qualify for payment for an initial new patient evaluation, 99202 or 99203 in addition to the surgery?

Answer: The NCCI reads: “If an E/M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E/M service is separately reportable with modifier 57.” Thus, the initial visit would be reported as CPT 99202-57 or 99203-57 in addition to the surgery charges, as the flap repair (adjacent tissue rearrangement) is a “major,” 90-day global procedure.