Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography, head or brain; without contrast
material, billed on October 7, 2022.
You asked the Plan to pay for this claim. You say that these services should be paid by the Plan. The Plan
denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans
denial. The Plan requested a reopen and stated that Maximus did not apply the correct billing criteria. The Plan
demonstrated that A National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists
between 70496 and 70450. This PTP edit has a modifier indicator of 1, modifiers associated with NCCI are
allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Per NCCI Chapter 1,
Section A - Introduction: The CMS developed the National Correct Coding Initiative (NCCI) program to
prevent inappropriate payment of services that should not be reported together. Prior to April 1, 2012, NCCI
Procedure-to-Procedure (PTP) edits were placed into either the "Column One/Column Two Correct Coding
Edit Table" or the "Mutually Exclusive Edit Table." However, on April 1, 2012, the edits in the "Mutually
Exclusive Edit Table" were moved to the "Column One/Column Two Correct Coding Edit Table" so
that all NCCI PTP edits are currently contained in this single table. Combining the 2 tables simplifies
researching NCCI PTP edits and online use of the NCCI tables. Each edit table contains edits which are pairs
of HCPCS/CPT codes that in general should not be reported together. Each edit has a Column One and Column
Two HCPCS/CPT code.
If a provider/supplier reports the 2 codes of an edit pair, the Column Two code is denied, and the Column
One code is eligible for payment. However, if it is clinically appropriate to use an NCCI PTP-associated
modifier, both the Column One and Column Two codes are eligible for payment. (NCCI PTP-associated
modifiers and their appropriate use are discussed elsewhere in this chapter.) Per NCCI Chapter 1, Section E -
Modifiers and Modifier Indicators: Modifiers may be appended to HCPCS/CPT codes only if the clinical
circumstances justify the use of the modifier. A modifier shall not be appended to a HCPCS/CPT code solely to
bypass an NCCI PTP edit if the clinical circumstances do not justify its use. If the Medicare program imposes
restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI PTP edit if the
Medicare restrictions are fulfilled. Modifiers that may be used under appropriate clinical circumstances to
bypass an NCCI PTP edit include: Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC,
LM, RI Global surgery modifiers: 24, 25, 57, 58, 78, 79. Other modifiers: 27, 59, 91, XE, XS, XP, XU
Modifiers 76 ("Repeat Procedure or Service by Same Physician") and 77 ("Repeat Procedure by
Another Physician") are not NCCI PTP-associated modifiers. Use of either of these modifiers does not
bypass an NCCI PTP edit. Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of "0"
indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit. A modifier indicator of "1"
indicates that NCCI PTP-associated modifiers may be used to bypass an edit under appropriate circumstances.
A modifier indicator of "9" indicates that the edit has been deleted, and the modifier indicator is not
relevant. Per the above Medicare guidelines, the Plan has correctly denied the code for payment.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. In this case, the documentation has confirmed that this claim could not be paid due to
an existing edit between the codes billed on the claim. Medicare rules for coverage of this claim have not been
met. Therefore, we decided that the Plan does not have to pay for computed tomography, head or brain; without
contrast material, billed on October 7, 2022.