Procedure to Procedure Edits

The purpose of the NCCI PTP edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services.

If a provider submits the two codes of an edit pair for payment for the same beneficiary on the same date of service, the Column 1 code is eligible for payment and the Column 2 code is denied. However, if both codes are clinically appropriate and a suitable NCCI associated modifier is used, the codes in both columns may be eligible for payment.

Although the Column 2 code is often a component of a more comprehensive Column 1 code, this relationship is not true for many edits. Several PTP code pair edits simply represent two codes that should not be reported together, unless an appropriate modifier is used. For example, a provider should not report a vaginal hysterectomy code and total abdominal hysterectomy code together.

The PTP edit table does not include all possible combinations of correct coding edits or types of unbundling that exist.

Medicare beneficiaries cannot be billed for services denied based on PTP edits since these denials are based on incorrect coding rather than medical necessity, the provider cannot seek payment from the beneficiary with or without an ABN.

The complete listing of NCCI PTP code pair edits are found in NCCI section of the CMS website.

Posted 3/3/2025