The Medicare NCCI promotes correct coding methodologies and controls improper coding leading to improper payment. Coding policies are based on coding conventions defined in the American Medical Association’s (AMA’s) Current Procedural Terminology (CPT) Manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, and/or current coding practice. Before implementing NCCI edits, CMS shares all NCCI proposed edits for review and comment with the AMA, national medical and surgical societies, and other national health care organizations, including non-physician professional societies, hospital organizations, laboratory organizations, and durable medical equipment (DME) organizations.
The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents. The CMS developed its coding policies 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. The CMS annually updates the National Correct Coding Initiative Policy Manual for Medicare Services.
The NCCI Policy Manual should be used by Medicare Administrative Contractors (MACs) as a general reference tool that explains the rationale for NCCI edits. MACs implemented NCCI PTP edits within their claim processing systems and CMS incorporated PTP edits into the outpatient code editor (OCE) for OPPS. These edits are applied to outpatient hospital services and other facility services including, but not limited to, therapy providers (Part B Skilled nursing facilities (SNFs)), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech-language pathology providers (OPTs), and certain claims for home health agencies (HHAs).
NCCI has 2 provider-type choices of Procedure to Procedure (PTP) code pair edits and 3 provider-type choices of Medically Unlikely Edits (MUEs). The purpose of the NCCI PTP edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services. Medicare Administrative Contractors (MACs) and DME MACs use MUEs, to reduce the improper payment rate for Part B claims. An MUE for an HCPCS/CPT code is the maximum units of service (UOS) that you would report under most circumstances for a single patient on a single date of service. Not all HCPCS/CPT codes have an MUE.
CMS wrote the Correspondence Language Manual and maintains it for use by the MACs to answer routine correspondence inquiries about the NCCI PTP and MUE edits. The general correspondence language paragraphs explain the rationale for the edits. The section-specific examples add further explanation to the PTP or MUE edits and are sorted by edit rationale and CPT code section (00000, 10000, 20000, etc.).
The NCCI contractor is able to address questions and concerns about NCCI edits and the program in general. However, because NCCI edits are implemented by the MACs as part of routine claim processing, claim-specific inquiries must be made to the MAC. This includes appeals of NCCI-related claim denials. Appeals must be submitted to your responsible MAC or QIC, not the NCCI Contractor. To file an appeal, please follow the instructions on the Appeals website. The NCCI contractor cannot process specific claim appeals, and cannot forward appeal submissions to the appropriate appeals contractor.
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