Are NCCI Edits and Modifiers Just for Medicare?
The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that being said, providers are still required to code correctly, regardless if there is a CCI edit or not.
Incorrect coding can lead to incorrect payments and the government is clear on how to handle incorrect payments and payment adjustments. These guidelines and rules are required to maintain compliance and help providers avoid denials. Using a CCI editor will let you know when one code is a component of another code and should not be billed together for the same beneficiary on the same day.
CMS Owns the NCCI Program
According to CMS; "The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents. CMS developed the CCI edits 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."
That being said, payers are not required to follow CMS' edits, however, these edits are the common coding guidelines that focus on codes that should not be reported together. As stated, the rules are a combination of the CPT manual and coding guidelines as well as the other resources mentioned above. Many coding experts use the same coding across the board, and using CMS edits is generally what is followed. If there is a question of un-bundling then it is suggested to address specific questions with the payer, national association, or society.
CCI Uses Two Types of Edits
CMS has built-in two types of edits to the NCCI editor;
# 1 Procedure-to-Procedure (PTP) - Pairs of HCPCS/CPT codes that should NOT be reported together; in other words, a procedure pertaining to an organ that cannot be removed by two different methods and should not be billed together unless a modifier is appropriate and allowed (it depends on the situation) such as:
- Vaginal hysterectomy (e.g. 58293 - Vaginal hysterectomy)
- Abdominal hysterectomy (e.g. 58200 - Total abdominal hysterectomy)
- 21249-Reconst of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete
- 21248- Reconst of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial
Since 21248 is a Column 2 (non-reimbursable) code in the following pairs:
Superscript 1 - Column 2 code may be reimbursed if an NCCI-associated modifier is appropriate and used.
# 2 Medically Unlikely Edits (MUEs) - Units of service. For example, it would be medically unlikely to bill 4 units of service for cataract extraction (66988), as there are only 2 eyes.
Place and Type
Now that we understand why the edits are there, let's take a look at the place and type of services where they are used. CMS has two different types of code pair edits used by Find-A-Code, Non-Facility, and Facility.
#1 Non-Facility - NCCI Edits-Physicians
These code pair edits are applied to claims submitted by physicians, non-physician practitioners, and Ambulatory Surgery Centers (ASCs) (provided that the code is listed as one of the Medicare-approved ASC procedures).
#2 Facility- NCCI Edits-Hospital Outpatient Prospective Payment System (PPS)
This set of code pair edits is applied to the Outpatient Code Editor (OCE). This is used by Hospitals, Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs), Part B, Outpatient Physical Therapy and Speech-Language Pathology Providers (OPTs), and Comprehensive Outpatient Rehabilitation Facilities (CORFs).
Column Edits with Numbers 0, 1 and 9
While the CCI edits may represent two codes that cannot reasonably be performed at the same site or encounter, there are times when a modifier is appropriate, allowing a bypass of the edit.
The following are other numbers next to a code indicating another purpose such as a modifier bypass:
0 means no modifiers are allowed
1 means modifiers may be used when appropriate
9 means the edit was deleted retroactively
Therefore, if a column 2 code is a component of a more comprehensive column 1 code, it may be noted as an exception and marked with a 1. For example, 95044 (Patch or application test) is a column 2 code. Because it is a component in the procedure 95130 (Professional services for allergen immunotherapy), it is marked with a 1.
Are Third-Party Payers using NCCI Edits?
There are several payers that have adopted CMS National Correct Coding Initiative (NCCI) edits and have implemented them into their claim scrubbers, such as Blue Cross and UnitedHealthcare. Due to the fact that NCCI edits are based on AMA CPT coding conventions and standard medical and surgical practices, if there are no other specific rules with your payer, these coding concepts will likely apply with most other payers. That being said, it is important that you understand each payer's coding rules and guidelines that are to be followed in order to receive correct and timely reimbursement.
NOTE: The information in this article is subject to each individual payer's rules and guidelines, and not meant to be all-inclusive to all payers.