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  
0 Votes - Sign in to vote or comment.

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)

To Our Codapedia Friends!
July 30th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Codapedia friends, come and join us at Find-A-Code - a core product of innoviHealth! The information found on Codapedia comes from our sister company, Find-A-Code. If you do not already have a subscription with the greatest online coding encyclopedia, call us and get signed up today. We are offering a ...
OIG Report Highlights Need to Understand Guidelines
July 28th, 2020 - Wyn Staheli, Director of Research
A new OIG report once again highlights the necessity for organizations to fully understand requirements for reporting services and having proper documentation. The types of problems addressed in this report are ongoing issues for multiple types of services and specialties and for many different payers.
Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately
July 21st, 2020 - Aimee Wilcox
We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...
Use the Correct Diagnosis Codes and Revenue Codes to Get Paid for PAD Rehab
July 15th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
The initial treatment in rehabilitation for patients suffering from Intermittent Claudication (IC) is Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD).  Rehabilitation using SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest.   When reporting 93668 for peripheral arterial disease rehabilitation the following ...
New Name Same Great Product! "HCC Plus"
July 14th, 2020 - Find-A-Code
Hello HCC Customers! We have made a change in name only to our HCC subscription. The new subscription is now called “HCC Plus”. Keep in mind there have been no changes to the product. Using your subscription along with the risk adjustment calculator will ensure you stay current with...
Are NCCI Edits Just for Medicare?
July 14th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
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 ...
Payment Adjustment Rules for Multiple Procedures and CCI Edits
July 9th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2020 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association