Minimize Your NCCI Denial Risk

Minimize Your NCCI Denial Risk

Maximize revenue cycle profits by watching bundling.

Becoming knowledgeable about National Correct Coding Initiative (NCCI) policies and edits may be the difference between having a profitable revenue cycle or placing your facility at risk for denials. In recent years, NCCI policies and edits have become key factors in outpatient facility and professional claims denials. You must have a strong understanding of these guidelines to ensure coding compliance and to mitigate risk. Let’s discuss some key concepts of the NCCI that may be placing your practice or facility at risk.

Follow NCCI Policy Manual Annual Updates

The NCCI Policy Manual is updated annually. The new guidance becomes effective Jan. 1 of each year. Because the purview of some external reviewers may extend back as far as three years, become familiar with the last three years of the NCCI Policy Manual.
Action Item: Pay special attention to claims denied during the first quarter of the year to ensure you are consistent with the most recent published guidelines.

NCCI Edits Are Updated Quarterly

NCCI edits are updated quarterly and are effective Jan. 1, April 1, July 1, and Oct. 1 each year. Because the NCCI Policy Manual is updated only annually, the quarterly updates may not correlate with the information published in the NCCI Policy Manual.
For example, the July 2016 NCCI updates eliminated the procedure-to-procedure code edits precluding the assignment of code 29823 Arthroscopy, shoulder, surgical; debridement, extensive with several other ipsilateral shoulder surgeries; however, the 2016 NCCI Policy Manual maintained the following language, “With the exception of the knee joint, arthroscopic debridement should not be reported separately with a surgical arthroscopy procedure when performed on the same joint at the same patient encounter.”
In this case, the encoder would no longer flag the debridement as not separately reportable by the procedure-to-procedure edits, but the language in the NCCI Policy Manual would still preclude the assignment of a debridement code with another ipsilateral arthroscopic shoulder surgery.
Action Item: Review the quarterly updates when they are published and compare them to the guidance published in the NCCI Policy Manual.

Not Every NCCI Policy Guideline Has an Edit

You may think that, if there isn’t an edit to preclude a particular code assignment, you can combine codes as you please.
Remember: Not every NCCI policy has an associated NCCI edit. Per the NCCI Policy Manual, “Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination.”
Action Item: Become familiar with guidelines published in the NCCI Policy Manual. Do not rely on your encoder, alone, to flag NCCI edit violations for code pairs.

CPT® Assistant Versus NCCI Policy Guidance

You may encounter cases where the guidance published in the NCCI Policy Manual differs from that published in CPT® Assistant. When this occurs, establish which set of guidelines has precedence. For Medicare claims, the NCCI policies prevail. According to page I-28 of the NCCI Policy Manual:
The American Medical Association publishes CPT® Assistant which contains coding guidelines. CMS does not review nor approve the information in this publication.
In the development of NCCI PTP edits, CMS occasionally disagrees with the information in this publication. If
a physician utilizes information from CPT® Assistant to
report services rendered to Medicare patients, it is possible that Medicare Carriers (A/B MACS processing practitioner service claims) and Fiscal Intermediaries may utilize different criteria to process claims.
Action Item: For commercial claims, know whether the payer follows NCCI edits prior to code assignment to ensure compliance.

Apply Policies to Your Healthcare Organization

These are just a few of the potential risks your practice or facility may prevent by having a thorough understanding of the NCCI policies.
Action Item: Coding managers should review the NCCI Policy Manual, and ensure their coding staff receives training on the sections applicable to their place of service.

Become familiar with guidelines published in the NCCI Policy Manual. Do not rely on your encoder, alone, to flag NCCI edit violations for code pairs.

The National Correct Coding Initiative (NCCI) was developed by the Centers for Medicare & Medicaid Services (CMS) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Medicare Part B claims. Although the NCCI policies were initially established for the Medicare program, several commercial insurers have adopted it.

 Susan J. Moore, MSHS, RHIT, CIC, COC, CDEO, CRC, CCS, CDIP, CHTS-TR, CCDS, AAPC Fellow, is an ICD-10-CM/PCS trainer and an independent coding and CDI professional, with over 20 years of experience in revenue cycle management. She is the education officer for
the Cleveland Area, Ohio, local chapter. You can contact Moore with questions at
The NCCI Policy Manual may be downloaded for free from the CMS website:
NCCI Quarterly Updates may be downloaded from the CMS website:


No Responses to “Minimize Your NCCI Denial Risk”

  1. S. Trader says:

    Please comment on the necessity of reporting all services on the facility claim for consideration in setting payment files for the coming year. If code pairs are bundled on the PTP table and no modifier is allowed or appropriate, would the facility coder need to check the facility NCCI edits tables to verify that the edit is in place on both tables (provider & facility) before he/she concludes that the code pair is appropriately bundled? I am reading an article entitled Compare and Contrast Physician and Outpatient Facility Coding which states “Tip: Never unbundle services on a professional claim; however, report all services on a facility claim (even non-covered services). Many services are not separately paid on the facility side, but are included in the payment for other services. It’s very important that all services appear on the facility claim. CMS gathers data from all facility claim lines for consideration in setting payment files for the next year.” Please respond at your earliest possible convenience.