National Correct Coding Initiative Edits
A revised annual version of the National Correct Coding Initiative Policy Manual for Medicare Services effective January 1, 2020 was posted with a Revision Date of November 12, 2019.
Revisions were made in Chapter VIII Section D (Ophthalmology), Chapter IX, Section E (Nuclear Medicine), Section F (Radiation Oncology) and Chapter X, Section A (Introduction), Section F (Molecular Pathology.)
Additions/revisions to the manual have been italicized in red font.
Additional prior versions of the National Correct Coding Initiative Policy Manual for Medicare Services are now available on this page in the NCCI Policy Manual Archive.
National Correct Coding Initiative
The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents. 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 societies, analysis of standard medical and surgical practices, and a review of current coding practices. The CMS annually updates the National Correct Coding Initiative Coding 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 Procedure-to-Procedure (PTP) edits within their claim processing systems for dates of service on or after January 1, 1996 and began implementing Medically Unlikely (MUE) edits on January 1, 2007.
A corresponding set of PTP edits is incorporated into the outpatient code editor (OCE) for OPPS. These edits are applied to outpatient hospital services and other facility services including, but not limited to, therapy providers (Part B Skilled nursing facilities (SNFs)), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech-language pathology providers (OPTs), and certain claims for home health agencies (HHAs) billing under TOBs 22X, 23X, 75X, 74X, 34X. Corresponding MUE edits are similarly implemented within the Fiscal Intermediary Shared System (FISS).
The purpose of the NCCI Procedure-to-Procedure (PTP) edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table have been combined into one table and include PTP code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual. The purpose of the NCCI MUE program is to prevent improper payments when services are reported with incorrect units of service.
The Correspondence Language Manual available below has been written and maintained for utilization by the Medicare Contractors to answer routine correspondence inquiries about the NCCI procedure to procedure (PTP) and MUE edits. The general correspondence language paragraphs explain the rationale for the edits. The section-specific examples add further explanation to the PTP or MUE edits and are sorted by edit rationale and CPT code section (00000, 10000, 20000, etc.). Please refer to the Introduction of this Manual for additional guidance about its use.
Inquiries about the NCCI program, including those related to NCCI (PTP, MUE and Add-On) edits, should be sent to the following email address: NCCIPTPMUE@cms.hhs.gov.
The NCCI contractor is able to address questions and concerns about NCCI edits and the program in general. However, because NCCI edits are implemented by the Medicare Administrative Contractors (MACs) as part of routine claim processing, claim-specific inquiries must be made to the MAC. This includes appeals of NCCI-related claim denials.
Appeals must be submitted to your responsible MAC or QIC, not the NCCI Contractor. To file an appeal, please follow instructions on the Appeals website. The NCCI contractor cannot process specific claim appeals, and cannot forward appeal submissions to the appropriate appeals contractor.
**NOTE** Any submissions made to the NCCI contractor that contains Personally Identifiable Information (PII) or Protected Health Information (PHI) are automatically shredded, regardless of the content, in accordance with federal privacy rules with which the NCCI Contractor must comply.
This web page provides information to providers on Medicare's NCCI edits but does not address specific NCCI edits. If the viewer has concerns about specific NCCI edits, they may submit comments in writing to:
National Correct Coding
P.O. Box 368
Pittsboro, IN 46167
Fax #: 317-571-1745