Medicare NCCI PTP + MUE quarterly files posted December 1, 2025, effective January 1, 2026 (Practitioner Services, Outpatient Hospital Services, DME Supplier Services).

CMS Posts 2026 Q1 Medicare NCCI Updates (PTP + MUE): What to Change Before January 1 Claims

Q: Did CMS post new MUE files for Q1 2026?

Yes. CMS lists Q1 2026 MUE quarterly additions, deletions, and revisions ZIPs for DME Supplier, Outpatient Hospital, and Practitioner Services posted December 1, 2025, effective January 1, 2026.

If your systems still enforce 2025 Q4 NCCI edits, a subset of January 2026 claims can deny automatically for exceeded unit caps or incompatible code pairing rules--even when the underlying service was legitimate.

Last updated: December 20, 2025

For practice owners, billing managers, compliance leads, RPM/RTM operators, and revenue cycle teams billing Medicare Part B.

How to use this page

This is an operational compliance guide, not legal advice. Use it to update unit-limit and code-pair logic in claim scrubbers and billing workflows against CMS’s published Medicare NCCI MUE and PTP quarterly files and change reports.

Who this affects

Recurring, high-volume billing patterns (RPM, RTM, CCM, APCM, repeat labs, supply spans)
Professional claims (Medicare Part B practitioner), outpatient hospital claims, and DME supplier claims
Teams with software or staff that can load too many units onto a single date of service

Thesis

Update your unit-of-service limits and code-pair edits now. Claim scrubbers and billing workflows that still enforce 2025 Q4 values will trigger denials the moment January 2026 claims hit MAC adjudication.

Section Index / Navigation Map

Key takeaway in one sentence
What CMS posted for January 1, 2026
What changed this quarter
What an MUE is and how it is adjudicated
What a PTP edit is and how it is applied
Common failure patterns that trigger denials
Why these patterns fail in audits and appeals
Edge cases and clarifications (MAI, modifiers, appeals, retroactive changes)
Practical implications for RPM, RTM, CCM, and APCM operations
Planning checklist
How FairPath enforces NCCI compliance
FAQ
References

Key Takeaway in One Sentence

Beginning January 1, 2026, Medicare claims that exceed updated NCCI MUE unit caps or violate updated PTP code-pair edits are subject to automated denials, so claim scrubbers and billing workflows must be updated to the CMS-posted Q1 2026 MUE and PTP files before January submissions.

What CMS Posted for January 1, 2026

On December 1, 2025, CMS published the Q1 2026 quarterly Medicare NCCI files (MUE and PTP), effective January 1, 2026. MUE tables remain separated by claim context, and PTP practitioner files are split into multiple segments by code range:

DME Supplier Services
Outpatient Hospital Services
Practitioner Services

CMS also publishes full tables and keeps only the current and prior quarter publicly visible, so internal version retention is operationally important. Replacement files can appear mid-quarter for both MUE and PTP.

What to download

MUE full tables for practitioner, outpatient hospital, and DME supplier services.
MUE quarterly additions, deletions, and revisions for practitioner, outpatient hospital, and DME supplier services.
PTP practitioner split files for the quarter (all segments if you cannot narrow your code ranges).
PTP quarterly additions, deletions, and revisions report if present.

What Changed This Quarter

Q1 updates commonly include a mix of MUE and PTP revisions that can affect remote care, facility, and supplier billing workflows:

New MUE caps for some codes, revisions to caps, and confidential MUEs that are not listed publicly.
New PTP edits, revisions, and deletions (retired edits).

Operators should refresh both MUE and PTP datasets in scrubbers prior to January claims and ensure the scrubber evaluates the correct table type (practitioner vs outpatient hospital vs DME).

This page does not reproduce CPT descriptors or code-level change lists. It focuses on operational steps to ingest the published updates and enforce them safely.

What an MUE Is and How It Is Adjudicated

Definition

Medicare’s National Correct Coding Initiative (NCCI) includes Medically Unlikely Edits (MUEs): automated unit-of-service ceilings to prevent improper payment when a CPT/HCPCS code is billed with an implausible quantity. An MUE is the maximum units reported for the same provider/supplier, same beneficiary, same date of service on the vast majority of appropriately reported claims. Not all codes have MUEs, and some values are confidential.

Tables by Context

CMS maintains separate tables for practitioner, outpatient hospital, and DME supplier services. The same code can have different behavior depending on the claim stream, so scrubbers must evaluate the correct table.

Claim-Line vs Date-of-Service

Claim-line MUEs (MAI 1): each claim line is compared to the MUE. If units on that line exceed the MUE, all units on that line are denied. Multiple lines with appropriate modifiers can adjudicate independently.
Date-of-service MUEs (MAI 2 or 3): all units for the same code, provider/supplier, beneficiary, date of service are summed across claim lines (regardless of modifiers). If the sum exceeds the MUE, all units for that code on the claim are denied.

MAI Implications

CMS uses an MUE Adjudication Indicator (MAI) to signal behavior:

MAI 2: policy-based, absolute date-of-service edit.
MAI 3: date-of-service edit with limited appeal paths when correctly coded and medically necessary.

The public MUE table shows the unit cap and a rationale category; MAI is defined in CMS NCCI guidance and is not reliably inferable from the cap alone.

What a PTP Edit Is and How It Is Applied

Definition

Procedure-to-Procedure (PTP) edits identify code pairs that should not be reported together for the same beneficiary on the same date of service. Each edit has a column 1 code (the primary service) and a column 2 code (the secondary service that is generally bundled or not separately payable).

CCMI Meaning

CCMI 0: not bypassable.
CCMI 1: potentially bypassable with an appropriate modifier and supporting documentation.
CCMI 9: not applicable or non-active edit context.

Effective and Deletion Dates

A populated deletion date means the edit is retired after that date.
A “*” means no deletion date is listed in the file for that quarter.

Modifier Warning

Do not use modifiers as a bypass flag; documentation must support distinct services, encounters, or structures consistent with CMS guidance.

Common Failure Patterns That Trigger Denials

MUE failure patterns

Quarterly refreshes not implemented, leaving scrubbers on prior-quarter caps.
Wrong table used (professional vs facility vs DME).
Posting multiple units to a single date of service when truing up monthly time.
Assuming line splitting can bypass date-of-service edits, even though MAI 2/3 sums units across lines.

PTP failure patterns

Billing incompatible pairs on the same date of service because monthly services are stamped to a single day.
Ignoring deletion dates and enforcing retired edits.
Using modifier 59 or X modifiers to force payment without a distinct-encounter or distinct-structure basis in documentation.

Why These Patterns Fail in Audits and Appeals

Claims processing logic is deterministic. CMS describes exactly how claim-line and date-of-service MUEs adjudicate, and how PTP edits apply to code pairs on the same date of service.
Denial coding is consistent across payers, but you should validate your remittance patterns. MUE unit-limit denials commonly remit as CO-151, while bundling or PTP-style denials commonly remit as CO-97.
Appeals depend on documented compliance with the edit logic, including correct table selection, date-of-service aggregation, and distinct-service justification when modifiers are used.

Edge Cases and Clarifications

Retroactivity

CMS positions NCCI edits as prospective; retroactive changes are unusual and must be explicitly dated. MACs are not expected to proactively identify retroactive claims but may address cases brought to their attention.

Appeals Above the Cap

MUE denials may be appealed to the MAC. For MAI 1 or 3, MACs may pay units above the MUE in some circumstances when correctly coded, counted, and medically necessary. MAI 2 operates as an absolute policy-based edit.

Replacement Files

CMS sometimes issues mid-quarter replacement files to correct edits. Operations need both quarterly updates and a lightweight path to ingest replacements for PTP and MUE.

Public vs Confidential Values

Some MUEs are confidential and may change status. Absence of a published value is not proof that no MUE exists.

PTP Deletion Dates

Deleted edits remain present in the file for historical context but should not be enforced after the deletion date.

Monthly DOS Compression

Many remote-care services are monthly but billed with one date of service, which increases both PTP collision risk and MUE ceiling exposure when multiple services or add-on units are stacked.

Practical Implications for RPM, RTM, CCM, and APCM Operations

Remote-care billing abstractions concentrate monthly work onto a single date of service. That compression can trigger both MUE unit caps and PTP collisions when multiple programs or add-on time increments land on the same DOS.

Operators should validate each month’s batch against the updated quarter’s MUE caps and PTP edits before submission.

Unit ceilings for add-on time increments.
One base-service per month logic to avoid overbilling the core service.
Mutual exclusivity between care-management programs to prevent code-pair collisions.

Planning Checklist

Download the Q1 2026 MUE files and change files for the correct claim context (practitioner, outpatient hospital, DME supplier).
Download the Q1 2026 PTP files for the quarter, including all practitioner segments if you cannot confirm the relevant code ranges.
Load PTP with deletion-date awareness so retired edits are not enforced after their deletion dates.
Refresh the full MUE tables and record the effective date/version in your compliance log; retain copies because CMS posts only current and prior quarters.
Update scrubber logic to evaluate the correct MUE table for the claim stream (professional vs facility vs DME).
Ensure scrubbers apply MAI behavior: claim-line vs date-of-service adjudication; avoid line splitting when MAI indicates date-of-service summation.
Implement mid-quarter replacement-file monitoring for both PTP and MUE.
Add denial monitoring: CO-151 commonly indicates MUE unit limits exceeded, while CO-97 commonly indicates bundling or PTP-style denials.

How This Fits the Broader CMS Trajectory

MUEs and PTP edits exemplify CMS’s shift toward front-end, automated program integrity. By encoding unit plausibility, code-pair logic, and modifier rules directly into claims processing systems through the NCCI framework, CMS limits improper payment before it happens. Remote care and care-management programs that are recurring and software-mediated are especially exposed because standardized edits now operate as policy enforced in code.

How FairPath Enforces NCCI Compliance

FairPath treats NCCI compliance as versioned policy:

Ingests quarter-dated NCCI rulesets for MUE and PTP and ties them to claim context.
Flags unit-limit issues before submission in the billing workflow.
Flags incompatible code-pair combinations and routes the item to correction prior to submission.
Exports a documentation snapshot suitable for attaching to the EMR.

FAQ

1

Did CMS post new MUE files for Q1 2026?

Yes. CMS’s Medicare NCCI MUE page lists Q1 2026 MUE quarterly additions/deletions/revisions ZIPs for DME Supplier, Outpatient Hospital, and Practitioner Services posted December 1, 2025, effective January 1, 2026.

2

Did CMS post new PTP files for Q1 2026?

Yes. CMS posted the Q1 2026 Medicare NCCI PTP practitioner files with a December 1, 2025 posting date and a January 1, 2026 effective date, alongside the quarterly change information.

3

How often do MUEs and PTP edits change?

At least quarterly. CMS can also issue replacement files mid-quarter, so compliance programs need both scheduled and ad hoc refresh paths.

4

What does a PTP deletion date mean?

A populated deletion date indicates the edit is retired after that date. The edit can remain in the file for historical context but should not be enforced once the deletion date has passed.

5

What is the difference between CCMI and MAI?

CCMI is the PTP Correct Coding Modifier Indicator that governs whether an edit can be bypassed with appropriate modifiers and documentation. MAI is the MUE Adjudication Indicator that determines claim-line versus date-of-service unit caps.

6

What remit codes do we commonly see when MUE or PTP edits are triggered?

MUE unit-limit denials commonly remit as CO-151, while bundling or PTP-style denials commonly remit as CO-97. Confirm actual remittance behavior with your MAC and remittance data.

References

Primary CMS sources

Standards / remittance coding references

X12 Claim Adjustment Reason Codes (CARC 151 and 97 definitions).