CMS Pub. 100-04, ch. 23, § 20.9.3.1

All PTP edits have a CCMI.

A denial of services due to a PTP edit is a coding denial, not a medical necessity denial. The presence of an

Advance Beneficiary Notice (ABN) shall not shift liability to the beneficiary for UOS denied based on a

PTP.

PTP edits with a CCMI of “0”:

On appeal, if the CCMI is a “0”, and the provider or supplier coded the claim correctly, there are no

circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the

same day by the same provider or supplier. If the reviewer determines that the claim was coded incorrectly

then, the review determination must repeat the generic language that appears in the MSN or remittance

advice notice pertaining to the NCCI edit. In addition, MACs must include the more detailed explanation of

the NCCI edit, which can be found in the standard correspondence language for MACs in the Medicare

NCCI Correspondence Language Manual.

PTP edits with a CCMI of “1”:

On appeal, if the correct coding initiative edit modifier indicator is a “1”, the reviewer must determine

whether the claim was coded correctly. For example, the reviewer should determine whether the provider or

supplier reported an incorrect code, a medically unnecessary service, or simply neglected to use a modifier.

The reviewer may change the initial determination only if the correct coding initiative edit has a modifier

indicator of “1” and the reviewer determines that an NCCI PTP-associated modifier could have been

appended to either code of a correctly coded edit code pair. If the reviewer determines that the claim was

coded incorrectly then, the review determination must repeat the generic language that appears in the MSN

or remittance advice notice pertaining to the NCCI edit. In addition, MACs must include the more detailed

explanation of the NCCI edit, which can be found in the standard correspondence language for MACs in the

Medicare NCCI Correspondence Language Manual.

General Instructions on PTPs:

• MACs shall assign CARC 236 with Group Code CO and MSN 16.8 for claims that fail the PTP edits,

and deny when this procedure or procedure/modifier combination is not compatible with another

procedure or procedure/modifier combination provided on the same day according to the NCCI program

or workers compensation state regulations/ fee schedule requirements.