CMS Reinstates NCCI Edits to CPT 92012 and 92014

Date: April 12, 2014

CMS has decided to reinstate the NCCI edits to CPT codes 92012 and 92014. Specifically, the edits bundle CPT codes 92012 and 92014 (established patient eye codes) into global surgery procedures based on CMS global surgery rules for reporting evaluation and management (E/M) codes on the same date of service as a global surgery procedure.

CMS had previously bundled these CPT codes into global surgical procedures, but because some MAC’s claims processing systems did not allow modifiers 24, 25, or 57 with 92012 and 92014, they suspended the edits. Effective April 1, 2014, the MAC processing systems allow these three modifiers with CPT codes 92012 and 92104. Therefore, CMS will re-implement these edits in the July 1, 2014 version of NCCI, and they will be retroactive to April 1, 2014, which is the date that the MAC processing systems were required to allow modifiers 24, 25, and 57 with CPT codes 92012 and 92014. Medicare contractors will not retroactively re-adjudicate claims back to April 1, 2014. However, any claims received on or after July 1, 2014 with dates of service on or after April 1, 2014 will be adjudicated against these edits.

Remember that an E/M service may be reported on the same day as a major surgical procedure (global period of 90 days) if the E/M service results in the initial decision to perform the procedure. Modifier 57 would be appended to the E/M code to indicate this.

For minor surgical procedures (global period of 0 or 10 days), an E/M service is separately reportable on the same day as the procedure only if significant and separately identifiable. An E/M service should not be reported solely for the decision to perform the minor surgical procedure. A significant and separately identifiable E/M service is indicated with modifier 25. For more information on the proper use of modifier 25, please visit our web site and request our FAQ or Distance Learning module on the topic.

An E/M service may also be reported with modifier 24 to indicate that it is an E/M service in the postoperative period of a global surgical procedure that is not related to the original procedure.

For more information, view the letter from NCCI here.

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