[ANSWERED] What are NCCI Edits?
According to Worldmetrics.org medical billing errors account for an estimated $68 billion in unnecessary healthcare costs annually. It goes without saying, but understanding the ins and outs of medical coding and billing are super important. Being able to accurately document services and procedures rendered during a visit can be the difference between receiving revenue on time or not.
However, some aspects of medical billing and coding can be a bit more complicated than others. One of them being National Correct Coding Initiative (NCCI) edits. Today, let’s go over what NCCI edits are and why they are important. Let’s get into it!
The NCCI is a program under the Centers for Medicare & Medicaid Services (CMS), which houses specific coding policies and edits. The CMS owns this program, deciding any decisions regarding the rules and regulations within.
They base the coding policies off of the content in the American Medical Association’s Current Procedural Terminology (CPT) Manual. As well as national and local policies/edits.
Other sources of information taken into consideration by the CMS include:
Coding guidelines developed by national societies
Analysis of standard medical and surgical practices
Review of current coding practices.
Originally formed in January of 1996, the purpose of the NCCI is to prevent improper coding. More specifically, to reduce instances of duplicate codes and ensure services rendered are medically appropriate. It promotes national correct coding of Medicare Part B claims. Medicare Part B tends to take care of medically necessary services and preventative services.
Some examples might include outpatient office visits or same day surgery.
It was in 2010 that the Affordable Care Act required CMS to notify states that Medicaid is compatible with all five Medicare NCCI methodologies. Today, NCCI edits are essential when processing both Medicare and Medicaid claims.
NCCI edits are often used for identifying incorrect code combinations and incorrect units of services recorded in a day.
There are two separate categories that make up NCCI edits: Procedure-to-Procedure (PTP) Edits and Medically Unlikely Edits (MUEs). PTP edits help to prevent providers from reporting incorrect payment of services together. The NCCI includes one table of edits for physicians or practitioners. They include another table of edits for outpatient hospital services. Column one for HCPCS, and Column two CPT. For reference HCPCS stands for Healthcare Common Procedure Coding System and CPT stands for Current Procedural Terminology.
If a report includes two codes of an edit pair on the same date of service, for the same beneficiary, only Column one code is eligible for payment. The Column two code is then denied. That is, unless proven clinically appropriate. The provider must then utilize the correct NCCI PTP-associated modifier in this case.
A great example is when a patient receives a surgery. The closure of the wound for that surgery is inherently included in the billing. You do not need to also bill separately for closing the wound on top of billing for the surgery.
An MUE is a unit of service edit for HCPCS and CPT codes. More specifically, for the maximum number of units you would bill for a service rendered by a single provider for a beneficiary on the same day.
These MUEs help to reduce errors when it comes to clerical entries and any incorrect coding based on the following criteria:
Anatomic considerations.
HCPCS/CPT code descriptors.
CPT coding instructions.
Established CMS policies.
Nature of a service/procedure.
Nature of an analyte.
Nature of the equipment.
Prescribing information.
Claims data.
Understanding how this edit works can help your practice reduce your paid claims error rate for Medicare claims. MUEs are either claim line edits or date of service edits. If the MUE is a claim line edit, each line of a claim is adjudicated against the MUE value for the HCPCS/CPT code on that claim line. If the unit of service on the claim line exceeds the MUE value, all units of service for that claim line are denied. If the same code is reported on more than one line of a claim by using CPT modifiers, each line of the claim is adjudicated separately against the MUE value of the code on that claim line.
If the MUE is a date of service MUE, all units of service for the HCPCS/CPT code reported by the same provider/supplier for the same beneficiary for the same date of service are summed. The summed value is compared to the MUE value. If the sum is greater than the MUE value, all units of service for the code on the current claim are denied.
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