(This article talks only about the Medicare Fee-For-Service Program / Original Medicare)
What is NCCI?
The Medicare National Correct Coding Initiative (NCCI) (also known as CCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. NCCI Procedure-to-Procedure (PTP) code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.
In addition to PTP code pair edits, the NCCI includes a set of edits known as Medically Unlikely Edits (MUEs). An MUE is a maximum number of Units of Service (UOS) allowable under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a provider on a date of service for a single beneficiary
How it Affects Health Care Professionals?
Accurate coding and reporting of services are critical aspects of proper billing. Service that is denied based on PTP code pair edits or MUEs may not be billed to Medicare beneficiaries; a provider cannot utilize an Advance Beneficiary Notice of Non-coverage (ABN) to seek payment from a Medicare beneficiary. The NCCI tools found on the CMS website help providers avoid coding and billing errors and subsequent payment denials. The NCCI tables are updated quarterly and loaded into the Medicare claims payment processing systems and onto the CMS NCCI webpages.
It is important to understand, however, that the NCCI does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent the use of an inappropriate code combination. Should providers determine that claims have been coded incorrectly, they are responsible to contact their Medicare Administrative Contractor (MAC) about potential payment adjustments.
Per a ruling on the Federal Register, providers and suppliers are subject to the statutory requirements found in section 1128J (d) of the Social Security Act and could face potential False Claims Act (FCA) liability, Civil Monetary Penalties Law (CMPL) liability, and exclusion from federal health care programs for failure to report and return an overpayment.
The NCCI is comprised of two provider-type choices of PTP code pair edits and three provider-type choices of MUEs:
PTP Code Pair Edits
These PTP code pair edits are applied to claims submitted by physicians, nonphysician practitioners, and Ambulatory Surgery Center (ASCs).
PTP edits are applied to Types of Bills (TOBs) subject to 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) billing under TOBs 22X, 23X, 75X, 74X, 34X.
These edits are applied to all claims submitted by physicians and other practitioners.
Durable Medical Equipment (DME) Supplier MUEs
These edits are applied to claims submitted to DME MACs. (At this time, this file will include HCPCS A-B and E-V codes in addition to HCPCS codes under the DME MAC jurisdiction.)
Facility Outpatient MUEs
These edits are applied to all claims for TOB 13X, 14X, and Critical Access Hospitals (CAHs) [85X].
The “National Correct Coding Initiative Policy Manual for Medicare Services” is available as a reference tool for correct coding and to explain the rationale for NCCI edits. Each chapter corresponds to a separate section of the “CPT Manual,” except Chapter 1, which contains general correct coding policies; Chapter 12, which addresses HCPCS Level 2 codes; and Chapter 13, which addresses Category III CPT codes. Each chapter is subdivided by subject to allow easier access to a particular code or group of codes.
The NCCI manual is available as a compressed (zipped) set of PDF documents on the National Correct Coding Initiative Edits webpage on the CMS website. To download or access the manual go to https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html on the CMS website.
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