Code edits are used by payers to prevent payment of services when incorrectly reported. When appropriately appended to a procedure code, a modifier may override a claims edit, allowing payment without need for submission of health records or an appeal. However, misuse of modifiers can result in denials, audits, and/or refund of previous payments.

We discuss the following in this article:

The Centers for Medicare & Medicaid Services National Correct Coding Initiative (NCCI) edits for Medicare and for Medicaid include 2 types of edits.

Other developers of coding edits may create payer-specific code edits based on a payer’s policies, Current Procedural Terminology (CPT®) instructions, and/or NCCI edits and rationales from Medicare or Medicaid.

Modifiers should not be appended when reporting multiple codes for unrelated services (eg, codes for an evaluation and management [E/M] service and laboratory tests) on the same date. Report modifiers based on CPT instruction,...

You do not currently have access to this content.