Decipher NCCI Edits
Correct coding relies on understanding the edit tables and what the columns mean.
By Ellen Hinkle, CPC, CPC-I, CPMA, CRC, CEMC, CFPC, CIMC
It’s important to understand how the National Correct Coding Initiative (NCCI) affects medical coding and provider reimbursement. The Centers for Medicare & Medicaid Services (CMS) implemented this initiative in 1996 to promote correct coding of Medicare services and reduce improper payments.
NCCI includes procedure-to-procedure (PTP) edits and medically unlikely edits (MUEs). The edits are listed in the NCCI tables posted on the CMS website, and are updated quarterly. The PTP edits consistent of HCPCS Level II/CPT® code pairs that are not reported together under normal circumstances. MUEs indicate the maximum number of units allowed for a HCPCS Level II/CPT® code on the same date of service for the same patient.
Look Up PTP Edits
PTP edits are located on the PTP Column 1/Column 2 tables. When a code pair is reported together for the same patient on the same date of service, think of the column 1 code as the “payable” code and the column 2 code as the “deniable” code.
There are reasons why one code would be paid and the other denied:
- The column 2 procedure is a component of the more extensive column 1 procedure; or
- The column 2 procedure is designated in the CPT® codebook as a “separate procedure,” and not reportable with the column 1 procedure.
There are also edits with rationales dictated by CPT® guidelines, standards of practice, and exclusivity.
The PTP tables include a modifier column for each coder pair. This column will contain a 0, 1, or 9, which indicates whether a modifier may be used to override the edit when an unusual circumstance warrants the performance of both (column 1 and column 2) procedures at the same encounter.
- “0” indicates a modifier is not allowed to override the edit. The column 2 code is not payable with the column 1 code.
- “1” indicates a modifier is allowed. Attaching the appropriate modifier to the column 2 code will bypass the edit and allow both procedures to be paid. Do not use a modifier just to bypass the edit. Documentation must support the unusual circumstances that warrant the performance of both services.
- “9” indicates a modifier is not applicable because the edit has been deleted.
See an example of a PTP in Figure A.
PTP edits based on a mutually exclusive rationale indicate the column 2 code is not payable with the column 1 code because one procedure cannot reasonably be performed at the same encounter or the same anatomic site as the other procedure. A few examples of the MUEs are:
- An initial inpatient visit cannot reasonably be performed at the same encounter as a subsequent inpatient visit.
- An appendectomy cannot reasonably be performed laparoscopically and via an open incision. Two different methods of removal cannot be performed to remove the same organ.
- A pregnancy test cannot reasonably be performed at the same encounter as a prostate exam. A pregnancy test is specific to females and a prostate exam is specific to males.
The code pairs often seem to be in the reverse order. That is, the column 1 (payable) code is often less extensive than the column 2 (deniable) code. Responding to questions about this, CMS said:
… for the mutually exclusive edits only, to promote correct coding and to deter providers from reporting codes improperly, CMS decided at National Correct Coding Initiative (NCCI) implementation on January 1, 1996 that the payable code should, in general, be the procedure with the lesser work Relative Value Unit (RVU), which often results in the lower payment between the two services.
Take Into Account MUEs
MUE tables, as shown below, identify a HCPCS Level II/CPT® code and the maximum number of units per date of service that Medicare will reimburse for the same patient. The MUE edits look at several factors to determine the allowable units of service. The code descriptor, CPT® coding guidelines, anatomic considerations, prescribing instructions, nature of analyte, etc., all play a role in this determination.
Note: Not all MUE edits are listed on the CMS website because some are kept confidential to ensure providers do not take advantage of a code with a high number of allowable units.
The MUE table is structured in columns. The first column provides the HCPCS Level II/CPT® code. The second column, titled “Practitioner Services MUE Values,” gives the maximum units of service the code may be reported for a date of service, for the same patient. The third column gives information on the MUE adjudication indicator, which defines the type of edit.
An MUE adjudication indicator of 1 indicates the units of service edit is applied at the line level. If it’s medically necessary to perform the service more than the allowed MUE value, report the additional units on separate lines with the appropriate modifier(s).
An MUE adjudication indicator of 2 indicates an “absolute” date of service edit. This edit stems from instructions within a code descriptor or based on anatomical structure. For example, CPT® 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes has an MUE adjudication indicator of 2 applied and an MUE value of 1, meaning it can only be billed once per date of service. The code descriptor includes the amount of time involved in performing the service. If more than the allotted time is spent providing the critical care services, CPT® guidelines instruct you to report +99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). To report more than one unit of code 99291 would be an “absolute” error.
An MUE adjudication indicator of 3 indicates a date of service edit. This is the most common of the per-day MUEs, and is based on clinical information. CMS believes it’s rare for the units of service to be higher than the MUE value assigned.
Now that you understand how these edits work, take some time to visit the CMS website and look up the codes you use to ensure you are coding correctly.
Ellen Hinkle, CPC, CPC-I, CPMA, CRC, CEMC, CFPC, CIMC, has more than 18 years of medical billing and coding and consulting experience. As a coding auditor for Visionary Health Group, she is primarily responsible for chart reviews, provider education, and teaching billing and coding classes, including AAPC’s PMCC curriculum to prepare students for the Certified Professional Coder (CPC®) certification exam. Hinkle is a member of the Indianapolis, Ind., local chapter.