If the NCCI edit does not permit a certain modifier, what action can a provider take?

When the National Correct Coding Initiative (NCCI) edit does not permit a certain modifier, the recommended course of action is to report additional work with modifier 22. This modifier is specifically designed to indicate that the service provided was significantly greater than what is typically associated with the procedure performed. By using modifier 22, the provider can communicate to the payer that the procedure involved more complexity or additional work than usual, which justifies a higher reimbursement.

This approach is effective because it aligns with the guidelines established by CMS, as modifier 22 is intended for that precise situation where the work involved exceeds the typical service expectations. Providers submitting claims with this modifier must also provide appropriate documentation in support of the claim, ensuring that the payer can understand the rationale behind the modifier’s use.

By considering this, the option of simply submitting the claim without any modifiers does not adequately convey the additional work done. Changing the procedure code might not be appropriate if the original procedure accurately describes the service provided, and using modifier 59 may not resolve the issue since it indicates a distinct procedural service rather than an increase in work or complexity. Therefore, using modifier 22 is the best way to accurately represent the additional work in cases where the NCCI edit does not accept a specific modifier