Medicare NCCI Edit for Billing CPT Codes 88363 and 88381‐26 for the Same Case

July 13, 2012

Medicare has an NCCI billing edit in their system that restricts the billing of CPT codes 88363 and 88380 or 88381 in conjunction with the same specimen. This edit is mutually exclusive and is not designed to be overridden through the use of any special modifiers, such as modifier 59. In fact, if billed together for the same specimen using the same date of service, one of the charges will deny for payment and quite possibly both charges could deny for payment depending on how the carrier handles such edits. Furthermore, it is not advisable to use different dates of service as the intent of this edit remains regardless of date of service.

Therefore, this edit applies to any Medicare or Medicaid claim and may also come into play with any commercial carriers who have instituted the NCCI CMS edits.