Are NCCI Edits Just for Medicare?

July 14th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS

Categories: CPT^® Coding Anesthesia|Pain Management Billing Cardiology|Vascular Dental Dermatology|Plastic Surgery Emergency Medicine Endocrinology ENT|Otolaryngology Gastroenterology Home Health|Hospice Internal Medicine Interventional Radiology Laboratory|Pathology Neurology|Neurosurgery Obstetrics|Gynecology Optometry Ophthalmology Oncology|Hematology Oral and Maxillofacial Surgery Orthopedics Physical Medicine|Physical Therapy Pediatrics Podiatry Primary Care|Family Care Pulmonology Radiology Rheumatology Skilled Nursing Urology|Nephrology Audits/Auditing Modifiers

The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that being said, providers are still required to code correctly, regardless if there is a CCI edit or not.

Incorrect coding can lead to incorrect payments and the government is clear on how to handle incorrect payments and payment adjustments. These guidelines and rules are required to maintain compliance and help providers avoid denials. Using a CCI editor will let you know when one code is a component of another code and should not be billed together for the same beneficiary on the same day.

CMS Owns the NCCI Program

According to CMS; "The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents. CMS developed the CCI edits based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices."

That being said, payers are not required to follow CMS' edits, however, these edits are the common coding guidelines that focus on codes that should not be reported together. As stated, the rules are a combination of the CPT manual and coding guidelines as well as the other resources mentioned above. Many coding experts use the same coding across the board, and using CMS edits is generally what is followed. If there is a question of un-bundling then it is suggested to address specific questions with the payer, national association, or society.

CCI Uses Two Types of Edits

CMS has built-in two types of edits to the NCCI editor;

# 1 Procedure-to-Procedure (PTP) - Pairs of HCPCS/CPT codes that should NOT be reported together; in other words, a procedure pertaining to an organ that cannot be removed by two different methods such as:

Vaginal hysterectomy (e.g. 58293 - Vaginal hysterectomy)
Abdominal hysterectomy (e.g. 58200 - Total abdominal hysterectomy)

# 2 Medically Unlikely Edits (MUEs) - Units of service. For example, it would be medically unlikely to bill 4 units of service for cataract extraction (66988), as there are only 2 eyes.

Place and Type

Now that we understand why the edits are there, let's take a look at the place and type of services where they are used. CMS has two different types of code pair edits used by Find-A-Code, Non-Facility, and Facility.

#1 Non-Facility - NCCI Edits-Physicians

These code pair edits are applied to claims submitted by physicians, non-physician practitioners, and Ambulatory Surgery Centers (ASCs) (provided that the code is listed as one of the Medicare-approved ASC procedures).

#2 Facility- NCCI Edits-Hospital Outpatient Prospective Payment System (PPS)

This set of code pair edits is applied to the Outpatient Code Editor (OCE). This is used by Hospitals, Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs), Part B, Outpatient Physical Therapy and Speech-Language Pathology Providers (OPTs), and Comprehensive Outpatient Rehabilitation Facilities (CORFs).

Column Edits with Numbers 0, 1 and 9

While the CCI edits may represent two codes that cannot reasonably be performed at the same site or encounter, there are times when a modifier is appropriate, allowing a bypass of the edit.

The following are other numbers next to a code indicating another purpose such as a modifier bypass:

0 means no modifiers are allowed

1 means modifiers may be used when appropriate

9 means the edit was deleted retroactively

Therefore, if a column 2 code is a component of a more comprehensive column 1 code, it may be noted as an exception and marked with a 1. For example, 95044 (Patch or application test) is a column 2 code. Because it is a component in the procedure 95130 (Professional services for allergen immunotherapy), it is marked with a 1.

Are Third-Party Payers using NCCI Edits?

There are several payers that have adopted CMS National Correct Coding Initiative (NCCI) edits and have implemented them into their claim scrubbers, such as Blue Cross and UnitedHealthcare. Due to the fact that NCCI edits are based on AMA CPT coding conventions and standard medical and surgical practices, if there are no other specific rules with your payer, these coding concepts will likely apply with most other payers. That being said, it is important that you understand each payer's coding rules and guidelines that are to be followed in order to receive correct and timely reimbursement.

NOTE: The information in this article is subject to each individual payer's rules and guidelines, and not meant to be all-inclusive to all payers.

###

Questions, comments?

If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.

Latest articles: (any category)

COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli

COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.

Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli

2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?
October 10th, 2023 - Aimee Wilcox

When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.

Accurately Reporting Signs and Symptoms with ICD-10-CM Codes
October 5th, 2023 - Aimee Wilcox

Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.

The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin Resistance
September 19th, 2023 - Aimee Wilcox

Diabetes is a chronic disease that just seems to consistently be increasing instead of improving resulting in a constant endeavor by medical researchers to identify causal effects and possible treatments. One underlying or precipitating condition that scientists have identified as a precipitating factor in the development of diabetes is insulin resistance, which is a known metabolic disorder. As data becomes available through claims reporting, additional code options become possible with ICD-10-CM.

Documenting and Reporting Postoperative Visits
September 12th, 2023 - Aimee Wilcox

Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period?

Understanding Gastroesophageal Reflux Disease and ICD-10-CM Coding
August 22nd, 2023 - Aimee Wilcox

Gastroesophageal reflux disease or GERD for short, is a disease that impacts millions of Americans on a weekly basis. Symptoms are uncomfortable, as are some of the tests used to diagnose it, but understanding the disease, tests, and treatments helps us better understand how to code the disease using ICD-10-CM codes.