Question

National Correct Coding Initiative (NCCI)

An advance clinical coding specialist/medical coder must have some knowledge of National Correct Coding Initiatives (NCCI). Research NCCI and describe who maintains the rules, purpose NCCI and what NCCI policies are based on. Finally relate NCCI to your day to day activities as a coder.

Answer 1

National Correct Coding Initiative (NCCI)

The National Correct Coding Initiative (NCCI) is a CMS program designed to prevent improper payment of procedures that should not be submitted together.

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims. 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. For an explanation of the rationale for NCCI edits and as a general reference, carriers and fiscal intermediaries can use the National Correct Coding Initiative Coding Policy Manual for Medicare Services, which is updated annually.

Types of Edits

NCCI includes three types of edits: NCCI procedure-to-procedure (PTP) edits, medically unlikely edits (MUEs), and add-on code edits.

PTP edits

Prevent inappropriate payment of services that should not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code, called a "pair." If a provider reports the 2 codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI-associated modifier is permitted and reported. The NCCI PTP edits are divided into two provider types:
- Practitioner are applied to claims submitted by physical therapists in private practice, as well as by other nonphysician practitioners and physicians, and by ambulatory surgery centers.
- Hospital are applied to claims submitted for services that are paid under the outpatient prospective payment system; for example, outpatient hospital services, Part B skilled nursing facilities, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers, and certain claims for home health agencies billing under types of claims.

Medically Unlikely Edits (MUEs)

Prevent improper payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service under most circumstances able to be reported by the same provider for the same beneficiary on the same date of service. MUEs are divided into three provider types:
Practitioner MUEs are applied to all claims submitted by physical therapists, physicians, and other practitioners.
DME Supplier MUEs are applied to claims submitted to DME MACs.
Facility Outpatient MUEs are applied to all claims for types of bills identified as 13X, 14X, and 85X (critical-access hospitals).

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 only if one of its primary codes is also eligible for payment.

Code Ranges

00000-09999: Anesthesia Services

10000-19999: Surgery (Integumentary System)

20000-29999: Surgery (Musculoskeletal System)

30000-39999: Surgery (Respiratory, Cardiovascular, Hemic and Lymphatic Systems)

40000-49999: Surgery (Digestive System)

50000-59999: Surgery (Urinary, Male Genital, Female Genital, Maternity Care and Delivery Systems) 60000-69999: Surgery (Endocrine, Nervous, Eye and Ocular Adnexa, and Auditory Systems)

70000-79999: Radiology Services

80000-89999: Pathology/Laboratory Services

90000-99999: Medicine, Evaluation and Management Services

A0000-V9999: Supplemental Services

0001T-0999T: Category III Codes

0001M-0010M: MAAA Codes

0001U-0034U: PLA Codes

Many procedure codes should not be reported together because they are mutually exclusive of each other. Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same beneficiary encounter. An example of a mutually exclusive situation is the repair of an organ that can be performed by two different methods. Only one method can be chosen to repair the organ. A second example is a service that can be reported as an initial service or a subsequent service. With the exception of drug administration services, the initial service and subsequent service cannot be reported at the same beneficiary encounter. In order to reduce the amount of claims denied sex/diagnosis and sex/procedure edits, the KX modifier is now a multipurpose informational modifier and will be used to identify services for transgender, ambiguous genitalia, and hermaphrodite beneficiaries in addition to its other existing uses. Therefore, if a gender/procedure or gender/diagnosis conflict edit occurs, the KX modifier alerts the MAC that it is not an error and will allow the claim to continue with normal processing.

When is a code the reimbursable code of a PTP code pair

The Column 1/Column 2 tables are comprised of PTP code pairs. If a provider submits the two codes of an edit pair for payment for the same beneficiary on the same date of service, the Column 1 code is eligible for payment and the Column 2 code is denied. However, if both codes are clinically appropriate and an appropriate NCCI-associated modifier is used, the codes in both columns are eligible for payment. Supporting documentation must be in the beneficiary’s medical record.