NCCI - (National Correct Coding Initiative)

NCCI edits are a set of rules established by CMS to prevent improper payments in medical
billing.

Surgery Section

Some services (like giving an injection or cleaning a wound) are already included as part of a
bigger medical/surgical procedure. These are called integral services, and you should not bill
them separately unless they are done as a stand-alone service.

Key Points to Understand:

1. Integral Services = Included

When a procedure is done, some smaller actions are considered "part of the job."

You don’t report them separately because they’re already included in the main procedure
based on standard medical practice.

2. Some Integral Services Have CPT Codes

Example:

CPT Code 36000 = Introduction of a needle into a vein (like during IV or injection).

Even though this has a code, you cannot report 36000 separately if it’s done as part of
another procedure, like nuclear medicine.

✅ You CAN report 36000 if putting the needle in the vein is the only thing being done.

❌ You CANNOT report 36000 if you’re doing it as part of a nuclear medicine procedure.

3. Some Integral Services Don’t Have Codes

Example: Wound irrigation (cleaning the wound).

There is no separate CPT code for this because it's just understood to be included when
treating wounds.

Introduction –

1. Pick the Right CPT Code

Rule: Always choose the exact CPT code that matches what was done to the patient.
Note: Don’t guess or approximate

If there is no specific code, then use an unlisted code (like 49999 for unlisted abdominal
procedure).

When you use an unlisted code, make sure the medical record includes a detailed
explanation of what was done.

Unlisted Procedure codes + “Special Report”

When the CPT book doesn’t have a code that fits, use the unlisted code for that section (e.g.,
26989 for unlisted pelvis/buttock procedure).

Attach a special report: what was done, why, how long it took, equipment, complexity — so
the payer can figure out payment.

2. Don't Get Confused by Section Names

Just because a code is under the Surgery section doesn’t mean it's always surgery.

✅ Example:

Peripheral artery stent is in the Surgery section

Heart (coronary) stent is in the Medicine section

4. Parenthetical notes (in CPT book) matter

Some CPT codes include notes that say “Do not report with...”

Why? Because the code may already include that service.

These instructions prevent duplicate or incorrect billing.

Example:

If 42820 (tonsillectomy + adenoidectomy) is used,

you shouldn’t code 42825 and 42830 separately – that would be unbundling and it’s
incorrect.

5. Don’t unbundle CPT codes

Some CPT codes (especially Category I and III) are “bundled” – meaning they already include
multiple steps.

You cannot break those components apart and bill them separately.

Example:
For laparoscopic cholecystectomy, you don’t separately bill for:

The incision

Accessing the site

Wound closure

→ Because all of these are considered part of the procedure.

6. When it is okay to report codes separately

If CPT guidelines say it’s allowed, then:

You can report additional codes for separately done services.

Example:

If you remove a benign skin lesion and then do a complex repair, both codes can be billed:

Excision of lesion (e.g., 11400)

Complex repair (e.g., 13132)

Because CPT repair guidelines say complex closure is not included in lesion excision.

7. The CPT Surgical Package (“global package”)

When you bill a surgical CPT code, all these pieces are already included in the price — you
don’t bill them separately:

The pre-op visit (history & physical) on the day before/day of surgery.

Local anesthesia (lidocaine, a digital block, etc.).

Immediate post-op work

Writing the op note, talking to family, writing orders.

Recovery-room check right after surgery.

Typical post-op follow-up (routine dressing change, stitch check, etc.).

Example: Code 27447 (total knee arthroplasty) already bundles the visit on the day of
surgery, the local anesthetic infiltration, and the routine post-op checks. You only code
27447 — nothing extra for those bundled services.

8. More than one procedure on the same day

You’ll need modifiers (Appendix A) to show payers what’s going on:

-51 Multiple Procedures: Same session, multiple surgical codes.

-59 Distinct Procedural Service (see below).

-58, -78, -79 for post-op-period return to OR scenarios.

“Separate Procedure” codes & modifier 59

A code labelled “separate procedure” is usually part of a bigger surgery, so you don’t bill it
with that bigger code.

If, however, the doc truly did it independently (different site, different session, etc.), you can
bill it — add modifier 59 to prove it was distinct.

Example: 49000 (Laparotomy, separate procedure) is included in an abdominal surgery like

44140 (Colectomy). But if the surgeon did an exploratory laparotomy in the morning and the
colectomy later that night as a separate session, you’d add 49000-59.

9. Foreign body vs. implant

If it was... Coding status

Intentionally placed by a clinician (stent, rod, pacemaker) It’s an implant.

Accidentally there (bullet, swallowed coin) It’s a foreign body.

Implant has broken/migrated and now acts like a hazard Treat as a foreign body unless
CPT has a specific removal code for that implant type.

Incision and Drainage (I&D)

What is Incision and Drainage?

Incision and drainage means:

Cutting open (incising) a lump, cyst, abscess, or infected area

Draining the pus, fluid, or infection out

This is commonly done for:

Abscess

Cysts

Seromas

Hematomas

Infected wounds

1. Don’t Bill I&D Separately if It’s Part of Another Procedure

If a doctor performs I&D just to help with another procedure, you cannot bill it separately.

Example:

A physician removes a pilonidal cyst (CPT 11770–11772).

During that process, the cyst might need to be incised and drained.

💡 DO NOT bill 10080 or 10081 for I&D here — it’s already part of the cyst excision
procedure.

2. Same Site, Same Encounter → Don’t Bill Separately

If a doctor does I&D and another procedure like:

Excision

Biopsy

Destruction

Repair

at the same location, at the same time, then:

💡 Only bill the main procedure

DO NOT bill the I&D code separately.

3. Postoperative Infections (Code 10180)

CPT 10180 = Incision and drainage of a complex postoperative wound infection

This code has strict rules:

❌ Don’t use 10180:

At the same time as the procedure that caused the infection.

💡 Example: If a surgery causes a wound infection and the doctor does I&D during the same
encounter, don’t bill 10180. It’s part of that surgery.

✅ You can use 10180:

Later, when the infection shows up after surgery, and the doctor is doing a separate
procedure to treat that infection.

✅ You can also use 10180:

If I&D is done at a different body site (not the one being operated on)

In short

Situation Can You Bill I&D Separately?

I&D done as part of another procedure at the same site and time ❌ NO

I&D done to gain access for another procedure ❌ NO

I&D done for separate infection, different site, or different encounter ✅ YES

CPT 10180 done for infection caused by earlier surgery (not on the same day) ✅ YES

CPT 10180 done during the same surgery that caused infection ❌ NO

Lesion Removal Coding

First, what is a Lesion?

A lesion is any abnormal skin growth or spot — like a mole, wart, cyst, tumor, or rash area.

1. Only ONE Removal Code per Lesion

Different methods for lesion removal have different CPT codes:

Destruction (freezing, laser, etc.)

Debridement
Paring/Cutting

Shaving

Excision

🔴 Important Rule:

If a lesion is removed using more than one method, only report the final/completed method.

Example: Started with shaving, but ended up doing excision → Code only the excision.

2. Multiple Lesions in One Removal Procedure?

If 3 lesions are removed together in one surgical step, use only one CPT code for that
removal.

✅ If different lesions are removed at different sites or using different methods, then you can:

Use anatomical modifiers (like -LT, -RT)

Or use Modifier 59 or XS to show they were distinct.

3. Don’t Bill Biopsy Separately If It’s the Same Lesion

If the doctor does a biopsy on the same lesion they are going to remove in the same visit,
then:

❌ Do NOT code the biopsy (CPT 11102–11107) separately — it’s included.

✅ You CAN bill biopsy if it was done on a different lesion.

4. Nail and Skin Rule

If you’re billing:

11055 (paring of callus)

11720 (nail debridement, 1–5 nails)

...and they’re done on the same toe/finger →

❌ Modifier 59/XS can’t be used. Don’t bill both.

5. Pathology Reporting (CPT 88300–88309)

Removed lesions are often sent for lab analysis (surgical pathology).
If all lesions are submitted as one specimen, bill only ONE pathology code.

✅ If each lesion is submitted separately, and location is clearly labeled, you can bill one
pathology code per lesion.

6. Review of Pathology Slides

If the physician personally reviews slides to decide about future treatment, and also bills for
an E/M service:

❌ Don’t report CPT 88321–88325 (surgical pathology consultation).

✔️It’s included in the E/M code.

7. Closure After Lesion Removal

Sometimes removing a lesion requires stitches or closure. Coding depends on complexity

and size:

Closure Type Is it Separately Billable? Notes

Dressing / Strip / Simple closure ❌ No Included

Intermediate or Complex closure ✅ Yes If medically necessary

8. Exception:

If the lesion is ≤ 0.5 cm (e.g., CPT 11400, 11420, 11440), then even complex closure is
included — don’t bill it separately.

✅ But if one lesion is >0.5 cm and needs complex closure → you can bill that.

Mohs Micrographic Surgery

What is Mohs Surgery?

Mohs Micrographic Surgery (CPT 17311–17315) is a special technique used to remove skin
cancer.
It’s used when the cancer is complex, ill-defined, or in a sensitive area (like the face).

In this surgery, one physician does both:

The excision (removal) of the skin tissue

The microscopic examination of the same tissue

1. Mohs Codes Already Include Several Services

When you use Mohs surgery codes (17311–17315), DO NOT separately bill the following:

Skin biopsy codes → 11102–11107

Excision of malignant lesion codes → 11600–11646

Destruction of malignant lesion codes → 17260–17286

Surgical pathology codes → 88300–88309, 88329–88332

📌 Why? These are already included in the Mohs procedure — do not unbundle.

2. When Biopsy Can Be Billed Separately

✅ You can bill a biopsy separately (CPT 11102–11107) if it was:

Done before the Mohs surgery

Done to confirm diagnosis of cancer before deciding to do Mohs

➡️In this case, use Modifier 59 (or XS, XU) or Modifier 58

Modifier 59 = Distinct procedure

Modifier 58 = Planned/staged procedure

Example:

Patient gets a biopsy to check for cancer → CPT 11102

Pathology confirms cancer

Doctor schedules Mohs surgery later → CPT 17311

✅ You can bill both 11102 and 17311, using modifier 59 or 58.

3. Frozen Section Pathology May Be Billed Separately

If the biopsy is done before Mohs and is sent for frozen section diagnosis (CPT 88331), then:
✅ You can bill 88331 with modifier 59 (or XS/XU/58)

BUT:

❌ Don’t bill 88331 or other pathology codes if they’re done as part of Mohs surgery.

They’re already included in CPT 17311–17315.

The frozen section procedure is a pathological laboratory procedure to perform rapid

microscopic analysis of a specimen

4. Repairs, Grafts, and Flaps Are Billable Separately

✅ If, after Mohs surgery, the doctor performs:

Complex wound repair

Skin grafts

Flaps

➡️These can be billed separately if medically necessary.

📌 Examples:

CPT 14040–14302 (flaps)

CPT 15100–15261 (grafts)

CPT 13100–13160 (complex repairs)

Intralesional Injections

What is an Intralesional Injection?

An intralesional injection means injecting medication directly into a lesion (like a cyst, keloid,
or psoriasis plaque).

There are two types of medications that can be injected:

Type CPT Codes Used For

Non-chemotherapy drugs (e.g., steroids) 11900–11901 Common skin conditions (e.g.,

acne cysts, keloids)

Chemotherapy drugs 96405–96406 Cancerous skin lesions

1. Don’t Bill Two Injection Codes Together

You cannot report two intralesional injection codes (like 11900 and 96405) together —
unless:

✅ The doctor:

Injects different lesions

Uses different types of drugs

➡️Then you can bill both with modifier 59 or XS to show they are distinct services.

Repair and Tissue Transfer

1. Types of Wound Repairs

Repairs (CPT 12001–13160) are classified as:

Simple – basic closure of superficial wounds (e.g., using sutures)

Intermediate – deeper layers (includes layered closure)

Complex – very deep or extensive closures, involving extensive undermining or scar revision

If closure can’t be done with these, the surgeon may use Adjacent Tissue Transfer (CPT
14000–14350), which means:

Cutting and moving nearby skin/tissue to cover the wound (like a flap).

Key Rules for Repair and Tissue Transfer:

Rule Explanation

✅ Adjacent tissue transfer (14000–14350) includes excision (11400–11646) and repair

(12001–13160) ❌ Don’t bill them separately for the same lesion/injury
✅ Debridement is included in tissue transfer ❌ Do not bill 11000–11047 or 97597–97602
with adjacent tissue transfer

✅ Complex repair ≠ tissue transfer If the surgeon just undermines tissue but doesn’t
cut/move it like a flap, it's complex repair, not tissue transfer

✅ Skin graft + repair or tissue transfer ✅ Bill separately only if graft is not included in
the tissue transfer code

❌ Wound repair done using tissue transfer methods (Z-plasty, W-plasty) for accidental
wound Use repair codes (not tissue transfer) unless surgeon designs a flap specifically

❌ Tissue culture or biopsy during repair or tissue transfer Included in the repair/transfer
code — not separately billable

Grafts and Flaps

CPT codes for grafts/skin substitutes (e.g., 15100–15278) are based on:

Size

Location

Type of graft (split-thickness, full-thickness, substitute, etc.)

Usually:

One primary code (e.g., 15100)

Add-on codes for larger sizes (e.g., 15101)

Quick Summary Table for Billers

Scenario Code(s) Bill Separately? Notes

Adjacent tissue transfer with excision or repair 14000 + 114XX or 120XX ❌ No

Included in tissue transfer

Debridement before grafting 11042 + 15200 ❌ No Included in grafting code

Graft done after tissue transfer 14040 + 15100 ✅ Yes Only if not included in
transfer code

Wound closed with Z-plasty after trauma 14040 ❌ No Use repair codes unless planned
flap
Complex undermining but no flap cut 13100 (Complex Repair) ✅ Yes Don’t use
tissue transfer code

Multiple grafts at different sites 15100 + 15200 ✅ Yes Use modifier 59 or XS

Surgeon cuts and moves adjacent skin to close defect 14000–14350 ✅ Yes True tissue
transfer

In simple : “Adjacent tissue transfer codes include the cutting and closure work — so don’t
add separate codes for excision, repair, or prep like debridement. But if the surgeon also
uses a skin graft that’s not part of the transfer code, it can be billed separately. Use modifiers
carefully when different areas are treated.”

Breast Procedures

Mastectomy vs. Excision Codes

CPT Codes Procedure

19300–19307 Mastectomy (complete/partial breast tissue removal)

19110–19126 Excision (removal of breast lesions, lumpectomy, etc.)

A mastectomy includes the removal of ALL breast lesions, so:

❌ Don’t bill excision codes with mastectomy for the same site.

When excision is separately reportable:

If excision is done before mastectomy to get pathology results that help decide if
mastectomy is needed

➡️You can bill both, using Modifier 58 to show staged procedures.

Breast Procedure Codes are Unilateral

Most breast CPT codes describe unilateral (one breast) procedures.

✅ If performed on both breasts, use:

Modifier 50 (bilateral) or

LT and RT modifiers, depending on payer policy.

Flaps During Reconstruction

| CPT 15734 | Flap (muscle/myocutaneous) from trunk |

❌ Do NOT bill 15734 with:

Reconstruction codes (19357–19364, 19367–19369) or

Implant codes (19340, 19342)

💡 Why? Because if a flap is used for reconstruction, it’s already included in the main code.