Background: NCCI Edits
The NCCI National Correct Coding Initiative is comprise of two provider-type choices of code pair edits and three provider-type choices of MUEs (Medically Unlikely Edits).
Code Pair Edits
1. NCCI Edits-Physicians
These code pair edits are applied to claims submitted by physician, practitioners, and Ambulatory Surgery Centers (ASCs).
2. NCCI Edits-Hospital
This set of code pair is applied to the following Types of Bills (TOBs) subject to the Outpatient Code Editor (OCE): Hospitals (TOB 12X and 13X), Skilled Nursing Facilities - SNFs (TOB 22X & 23X), Home Health Agencies - HHAs Part B (TOB 34X), Outpatient Physical Therapy and Speech-Language Pathology Providers - OPTs (74X) and Comprehensive Outpatient Rehabilitation Facilities - CORFs (TOB 75X).
Medically Unlikely Edits (MUEs)
1. Practitioner MUEs
All physician and other practitioner claims are subject to these edits.
2. Durable Medical Equipment (DME) Supplier MUEs
These edits are applied to claims submitted to DME MACS. (At this time, this file includes HCPCS A-B, D-H, K-V codes in addition to HCPS codes under the DME MAC jurisdiction.)
3. Facility Outpatient MUEs
Claims for TOB 13X, 14X and Critical Access Hospitals (85X) are subject to these edits.
The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control leading to appropriate payment in Part B claims. 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 sociates, analysis of standard medical and surgical practices, and review of current coding practices. The CMS annually updates the National Correct Coding Initiative Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual should be utilized by carriers and FIs as a general reference tool that explains the rationale for NCCI edits.
Carriers implemented NCCI edits within their claim processing systems for dates of service on or after January 1, 1996.
Resources: How to use NCCI Tools? < - - - Click this link for the pdf file
National Technical Information Service - CCI or NCCI
Resources: How to use NCCI Tools? < - - - Click this link for the pdf file
National Technical Information Service - CCI or NCCI
About the current issue from National Technical Information Service (NTIS)
NTIS is CMS's authorized distributor of CCI codes. CMS issues new manual every three months. Each edition represents the latest codes available as authorized by CMS.
When filling claims from:
- January 1 to March 31, 2014, you should use Version 20.0
- April 1 to June 30, 2014, you should use Version 20.1
- July 1 to September 30, 2014, you should use Version 20.2
- October 1 to December 31, 2014, you should use Version 20.3
Why providers must have National Correct Coding Initiative Edits Code?
- To ensure you are getting the information as provided by CMS by purchasing your correct coding product from National Technical Information Service (NTIS).
- To avoid claim denials, delays and audits by keeping current with CMS's correct coding policies.
- NTIS offers variety of products that show you which codes cannot be used together in your reimbursement claims.
- With more than 650,000 pairs of codes (edit pairs) that cannot be used in the same claim, these correct coding products are a must for all offices involved with Part B Medicare services. All electronic and paper copies also contain the updated:
- Introduction to the Correct Coding Initiate
- General Correct Coding policies
- Policy Narratives that will help you understand the edits
- State by state listing of Medicare Part B Carriers to know who to call with questions.
CPT is a registered trademark of the American Medical Association.
The CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for the HCPCS/CPT code is the maximum Units of Service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service. All HCPCS/CPT codes do not have an MUE. MUE was implemented January 1, 2007 and utilized to adjudicate claims at Carriers, Fiscal Intermediaries, and DME MACs.
Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS Contractors use only. The latter group of MUE values should not be released since does not publish them.
Remember that MUE tables are updated quarterly just like code pairs and saved tables must be replaces in order to have the most current information.
Helpful Hint: Unlike the code pair tables, the MUE tables do not have a column that addresses modifiers. Review Chapter 1 of the "National Correct Coding Initiative Policy Manual for Medicare Services" for information about modifiers and MUEs.
Using the "National Correct Coding Initiative Policy Manual For Medicare Services
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. Neither the introduction nor the narrative portion of any chapter is intended to supersede any current Medicare policy.
The Introduction and Chapter 1 of the manual are excellent resources for basic information about proper coding practices and how coding edit decisions are made. Chapter 1, which is entitled “General Correct Coding Policies,” addresses general coding principles, issues, and policies. Many of these principles, issues, and policies are addressed further in subsequent chapters dealing with specific groups of HCPCS/CPT codes. Examples are often utilized to clarify principles, issues, or policies. The examples do not represent the only codes to which the principles, issues, or policies apply.It is also highly recommended that you carefully review the chapters of the manual that pertain to the code ranges you most often bill. These chapters include detailed information about correct coding and use of NCCI-associated modifiers for separately reportable services, and much more.
1. The manual is available as a compressed (zipped) set of PDF documents on the National Correct Coding Initiative Edits web page on the CMS website. To download or access the manual:
Go to http://www.cms.gov/NationalCorrectCodInitEd on the CMS website. Scroll down to the Downloads section of the page and click on the “NCCI Policy Manual for Medicare Services” PDF/ZIP file.
A file download pop-up box will appear. Click on Open to simply view the file. Click on Save to save the manual for future use. The manual will open or save as multiple PDF files, one for each chapter of the manual.
2. National Technical Information Service (NTIS) is the official distributor of the NCCI edits. The “NCCI Policy Manual” or sections of the manual can be ordered from NTIS on its website athttp://www.ntis.gov/products/cci-asciidl.aspx or by calling 1-800-363-2068.
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html
The CMS National Correct Coding Initiative (NCCI) promotes national correct coding methodologies and reduces improper coding, which may result in inappropriate payments of Medicare Part B claims and Medicaid claims. The Medicaid NCCI program has significant differences from the Medicare NCCI program. The National Correct Coding Initiative in Medicaid web page provides information and resources about NCCI policies under the Medicaid program.
Modifier -59 Article
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf
This article provides information about CPT Modifier -59, an important NCCI-associated modifier that is often used incorrectly.
Internet-Only Manual (IOM) Pub 100-04
“Medicare Claims Processing Manual” - (IOM) Pub 100-04
http://www.cms.gov/manuals/downloads/clm104c23.pdf
Chapter 23 is entitled “Fee Schedule Administration and Coding Requirements.” Section 20.9, “Correct Coding Initiative (CCI),” provides instructions regarding implementation of NCCI edits and MUEs including information on modifiers.
CMS Outpatient Code Editor (OCE) Web Page
http://www.cms.gov/OutpatientCodeEdit/01_Overview.asp
This web page provides an overview of the OCE, as well as information on the OCE versions and updates.
RESOURCES:
The National Correct Coding Initiative in Medicaidhttp://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html
The CMS National Correct Coding Initiative (NCCI) promotes national correct coding methodologies and reduces improper coding, which may result in inappropriate payments of Medicare Part B claims and Medicaid claims. The Medicaid NCCI program has significant differences from the Medicare NCCI program. The National Correct Coding Initiative in Medicaid web page provides information and resources about NCCI policies under the Medicaid program.
Modifier -59 Article
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf
This article provides information about CPT Modifier -59, an important NCCI-associated modifier that is often used incorrectly.
Internet-Only Manual (IOM) Pub 100-04
“Medicare Claims Processing Manual” - (IOM) Pub 100-04
http://www.cms.gov/manuals/downloads/clm104c23.pdf
Chapter 23 is entitled “Fee Schedule Administration and Coding Requirements.” Section 20.9, “Correct Coding Initiative (CCI),” provides instructions regarding implementation of NCCI edits and MUEs including information on modifiers.
CMS Outpatient Code Editor (OCE) Web Page
http://www.cms.gov/OutpatientCodeEdit/01_Overview.asp
This web page provides an overview of the OCE, as well as information on the OCE versions and updates.
