The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiatives (NCCI) edits in 1996 to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims.
These edits, based on the CMS coding policies, use coding conventions defined in the American Medical Association's CPT Manual (AMA CPT), 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.
NCCI includes three types of edits, which are discussed below.
NCCI PROCEDURE-TO-PROCEDURE EDITS
These are developed to prevent improper payment when incorrect code combinations are reported.
The NCCI procedure-to-procedure (PTP) edits prevent inappropriate payment of services that should not be reported together. Each edit has a Column 1 and Column 2 HCPCS/CPT code. If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service (DOS), the Column 1 code is eligible for payment, but the Column 2 code is denied unless a clinically appropriate NCCI-associated modifier is also reported.
For example, an excision of a benign lesion (including margins) on the trunk with total excised diameter of 1.6 cm when reported at the same time as a skin biopsy performed on a different lesion from that which is excised is reported as follows:
11402
11100 - 59
MEDICALLY UNLIKELY EDITS
These are developed to reduce the paid claims error rate for Part B claims. Medically unlikely edits (MUEs) for an HCPCS/CPT code are the maximum units of service that a provider can report under most circumstances for a single beneficiary on a single DOS.
MUEs prevent payment for an inappropriate number/quantity of the same service on a single day. These edits are based on the following:
[check mark] Anatomic considerations
[check mark] HCPCS/CPT code descriptors
[check mark] CPT instructions, CMS policies
[check mark] Nature of service/procedure
[check mark] Nature of analyte
[check mark] Nature of equipment
[check mark] Clinical judgment
For example, complex repair code 13121-scalp, arms, and/or legs; 2.6-7.5 cm has an MUE of 1 because of anatomical consideration:
Note: Not all HCPCS/CPT codes have an MUE.
ADD-ON CODE EDITS
Add-on code edits consist of a listing of HCPCS and CPT add-on codes with their respective primary codes. An add-on code is eligible for payment if, and only if, one of its primary codes is also eligible for payment.
For example, additional destruction of premalignant lesion(s; actinic keratosis), second to 14 lesions, cannot be reported without the primary destruction code 17000 on the same DOS as follows:
17000
+17003
POLICY MANUAL BACKGROUND
The NCCI Policy Manual for Medicare Services and NCCI edits have been developed for application to Medicare services billed by a single provider for a single patient on the same DOS. The edits were developed for the purpose of encouraging consistent and correct coding and reducing inappropriate payment and do not include all possible combinations of correct coding edits or types of unbundling that exist. Healthcare providers are obligated to code correctly even if edits do not exist to prevent the use of an inappropriate code combination. If a provider determines that he or she has been coding incorrectly, the provider should contact his or her Medicare Administrative Contractor about potential payment adjustments.
Previously, there were two files developed and maintained by the CMS:
[check mark] MUEs
[check mark] NCCI PTP or the mutually exclusive edits
In 2012, CMS consolidated the two files and now only publishes the PTP coding edit file that can be found at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.h.
The consolidation into Column 1/Column 2 correct coding edit file has helped simplify the use of the PTP edit files. With this, edits appear in the single Column 1/Column 2 correct coding edit file.
NCCI POLICY TODAY
Now, the CMS posts PTP and MUE quarterly version updates to its NCCI PTP and MUE at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Chan.
The CMS reserves the right to publish all MUE values that are 4 or higher because of concerns about fraud and abuse. National healthcare organizations and contractors with information about MUE values that are not published on the CMS Web site should continue to maintain confidentiality of those values. In addition, a minimal number of MUEs with lower values that are believed by CMS to be particularly vulnerable to fraud and abuse may not be published.
NCCI edits are utilized by Medicare claims processing contractors to adjudicate provider claims for physician services, outpatient hospital services, and outpatient therapy services. They are not applied to facility claims for inpatient services.
As such, healthcare providers are discouraged from incorrectly interpreting MUE values as utilization guidelines. MUE values do not represent units of service that may be reported without concern about medical review. Providers must continue to only report services that are medically reasonable and necessary.
CPT codes representing services denied based on NCCI edits cannot be billed to Medicare beneficiaries. Because these denials are based on incorrect coding rather than medical necessity, the provider cannot utilize an "advanced beneficiary notice" form to seek payment from a Medicare beneficiary. Furthermore, because the denials are based on incorrect coding rather than a legislated Medicare benefit exclusion, the provider cannot seek payment from the beneficiary with or without a "notice of exclusions from Medicare benefits" form.
Because the NCCI is a CMS program, its policies and edits represent CMS national policy. However, NCCI policies and edits do not supersede any other CMS national coding, coverage, or payment policies.
Sometimes, other payers may utilize the NCCI edits as they deem necessary. It is important for dermatology practices to check other payer contracts to determine if they use the NCCI policies to allow for correct coding and claim processing.
The latest package of PTP CCI edits, Version 22.2, effective July 1, 2016, is now available via the CMS Data Center at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.
Choose the Version 22.2, "Practitioner PTP Edits," to view.
For more information, please see the following: "Overview and Background," https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html, and "Frequently Asked Questions," https://questions.cms.gov/faq.php?id=5005&rtopic=1867&rsubtopic=7005.