Glossary · Compliance

Novitas Solutions

Novitas Solutions is a Medicare Administrative Contractor (MAC) that processes Part A and Part B claims for providers in two jurisdictions: Jurisdiction H (AR, CO, LA, MS, NM, OK, TX, Indian Health, and Veterans Affairs) and Jurisdiction L (DC, DE, MD, NJ, PA). It publishes coding guidance, modifier fact sheets, and NCCI-related policies that directly govern claim adjudication for orthopedic and other specialty providers in those regions.

Verified May 8, 2026 · 10 sources ↓

Drawn from NovitasCMS

Definition

Source · Editorial summary grounded in 10 cited references ↓

Novitas Solutions, Inc. operates as a Medicare Administrative Contractor under contract with the Centers for Medicare & Medicaid Services (CMS). It administers Medicare Part A and Part B claims for two distinct geographic jurisdictions: Jurisdiction H (JH), covering Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, Indian Health Service facilities, and Veterans Affairs providers; and Jurisdiction L (JL), covering the District of Columbia, Delaware, Maryland, New Jersey, and Pennsylvania. Providers in these regions submit claims to Novitas for adjudication, coverage determination, and payment.

Novitas publishes a wide array of compliance and coding resources on its provider-facing portals (novitas-solutions.com). These include modifier fact sheets for high-scrutiny modifiers such as 25, 59, 62, and 96/97; NCCI procedure-to-procedure (PTP) edit guidance; Medically Unlikely Edit (MUE) explanations; E/M coding guidance incorporating AMA 2021 and 2023 changes; specialty code tables; and links to CMS Internet-Only Manuals. For orthopedic surgery (specialty code 20), Novitas guidance on surgical modifiers, global surgery packages, and NCCI edits is particularly consequential.

Although providers are ultimately responsible for correct CPT, HCPCS, and ICD-10-CM code selection—per CMS IOM Pub. 100-09, Chapter 6, Section 30.3.1—Novitas serves as the first-line claims reviewer and denial issuer. Its local coverage determinations (LCDs), correct coding modifier indicators (CCMIs), and automated prepayment edits define the practical rules of reimbursement for in-jurisdiction orthopedic practices. Understanding Novitas-specific policies is therefore a prerequisite for compliant billing, not merely a best practice.

Why it matters

Orthopedic practices billing in Jurisdiction H or L that ignore Novitas-specific modifier rules and NCCI edit guidance face automated prepayment denials, post-payment audits, and potential overpayment recoupment. For example, Novitas applies NCCI PTP edits and global surgery rules sequentially on the same claim—correct coding edits first, then global surgery edits—so appending modifier 59 or 25 without documentation that clearly supports a distinct or separately identifiable service will not override a denial. A single miscoded arthroscopy with an unsupported modifier 59 can trigger a full claim denial; a pattern of such errors can escalate to a Targeted Probe and Educate (TPE) review or a formal audit referral.

Common mistakes

Where people most often go wrong with this concept.

Source · Editorial brief grounded in cited references ↓

Assuming Novitas modifier policies are identical to other MACs—Novitas publishes jurisdiction-specific fact sheets for modifiers 25, 59, and others that contain guidance beyond the CMS baseline.
Appending modifier 59 when a more specific X-modifier (XE, XS, XP, or XU) better describes the distinct circumstance, increasing audit exposure under Novitas NCCI review.
Using modifier 25 on the same claim as a minor procedure without ensuring the medical record explicitly documents a separately identifiable, medically necessary E/M service—Novitas applies PTP edits before global surgery edits, so inadequate documentation results in denial of the E/M.
Failing to check the Novitas Novitasphere portal for jurisdiction-specific LCD or article updates before billing new orthopedic procedures, leading to claim submission under a coverage policy that has already been updated.
Billing units that exceed the CMS-published MUE for a given CPT code without appending the appropriate modifier and documentation to justify the overage, resulting in automatic line-level denial.
Treating Novitas JH and JL as interchangeable when verifying coverage policies—each jurisdiction maintains separate policy pages and may have different LCD effective dates for orthopedic services.

Related codes

Codes commonly involved when this concept appears in practice.

CPT

ICD-10

M17.11

Modifiers

25 Significant separately identifiable E/M 59 Distinct procedural service 22 Increased procedural services 51 Multiple procedures 62 Two surgeons XS Separate structure

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 10 cited references ↓

01Which states does Novitas Solutions cover for Medicare billing?

Novitas administers Medicare claims for two jurisdictions. Jurisdiction H covers Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, Indian Health Service facilities, and Veterans Affairs providers. Jurisdiction L covers the District of Columbia, Delaware, Maryland, New Jersey, and Pennsylvania.

02How does Novitas apply NCCI edits and global surgery edits on the same orthopedic claim?

Novitas applies NCCI correct coding edits first, then applies global surgery edits to the resulting correctly coded services. This sequential application means a modifier that bypasses an NCCI edit will still be subject to global surgery scrutiny—documentation must independently satisfy both standards.

03Where can orthopedic coders find Novitas-specific modifier guidance?

Novitas publishes modifier fact sheets and a complete modifier listing on its jurisdiction portals at novitas-solutions.com. Separate pages exist for modifiers 25, 59, and other CPT modifiers (96/97), and a modifier lookup tool is available for Part B providers under the JL Claims Center.

04What is Novitasphere and why does it matter for orthopedic practices?

Novitasphere is Novitas's secure online portal where enrolled providers can submit claims electronically, check claim status, view remittance advice, and access jurisdiction-specific policy updates. Practices that do not monitor the portal risk missing LCD changes or coding updates that affect orthopedic procedure coverage.

05Does Novitas publish Medically Unlikely Edit (MUE) values for orthopedic CPT codes?

Novitas directs providers to the CMS MUE table for published values. Some MUE values are confidential and withheld from public view. Exceeding the MUE for any CPT code without appropriate modifier and documentation support will result in automatic line-level denial under Novitas claim processing.

06Is Novitas responsible for determining which CPT or ICD-10-CM codes a provider should use?

No. Under CMS IOM Pub. 100-09, Chapter 6, Section 30.3.1, providers bear full responsibility for selecting the correct diagnostic and procedural codes for services furnished to Medicare beneficiaries. Novitas publishes guidance to help providers comply, but code selection accountability remains with the billing provider.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

When Mira is generating or reviewing documentation for a Novitas JH or JL provider, apply the following jurisdiction-specific logic: 1. MODIFIER 25: The medical record must contain a clearly distinct chief complaint, history, exam, and medical decision-making (MDM) or total time rationale that is separate from the procedure note. Novitas auditors will review both documents; a procedure note that doubles as the E/M note will not satisfy the separately identifiable standard. 2. MODIFIER 59 / X-MODIFIERS: Flag any claim line where two non-E/M codes share the same date of service. Confirm the NCCI CCMI for that code pair. If CCMI = '1', select the most specific X-modifier (XS for separate structure, XE for separate encounter, XP for separate practitioner, XU for unusual non-overlapping service) rather than defaulting to 59. Document the anatomic or temporal distinction explicitly in the operative or procedure note. 3. MUE COMPLIANCE: Before finalizing units of service for any CPT code, cross-reference the CMS-published MUE table. If medically necessary units exceed the MUE, append modifier 59 or an X-modifier and ensure the note quantifies the clinical rationale for each unit. 4. G2211 ADD-ON: For office/outpatient E/M visits in a Novitas jurisdiction where the surgeon is managing a complex ongoing orthopedic condition (e.g., post-surgical complications, multi-level spine disease), evaluate whether G2211 is appropriate. Do not report G2211 with modifier 25 on the same claim line. 5. GLOBAL SURGERY: For 0- and 10-day global procedures, Novitas applies NCCI PTP edits before global surgery edits. Ensure any same-day E/M is documented as unrelated to the procedure or clearly meets modifier 24/25 criteria.

See Mira's approach

A Medicare Administrative Contractor (MAC) is a private insurance company under contract with CMS to process and pay Medicare Part A and Part B fee-for-service claims within an assigned geographic jurisdiction. MACs are the primary point of contact for providers on coverage policies, claims adjudication, and local coverage determinations.

Local Coverage Determination (LCD) Compliance

A Local Coverage Determination (LCD) is a regional Medicare policy issued by a Medicare Administrative Contractor (MAC) that defines when a specific service, procedure, or supply is considered reasonable and medically necessary within that contractor's jurisdiction.