Medicare National Correct Coding Initiative (NCCI) Edits
CMS developed the NCCI program to promote national correct coding of Medicare Part B claims. CMS owns the NCCI program and is responsible for all decisions regarding its contents.
CMS develops its coding policies based on coding conventions defined in the American Medical Association’s Current Procedural Terminology (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 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 or practitioners and one table of edits for outpatient hospital services. The purpose of the NCCI Medically Unlikely Edits (MUE) program is to prevent improper payments when services are reported with incorrect units of service. Refer to the How to Use NCCI Tools booklet (PDF) for more information.
MACs implement NCCI PTP edits within their claim processing systems, and CMS incorporates PTP edits into the outpatient code editor (OCE) for the Outpatient Prospective Payment System (OPPS). These edits apply 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 Type of Bills (TOBs) 22X, 23X, 75X, 74X, 34X. MACs similarly implement Medically Unlikely (MUE) edits and corresponding MUE edits within the Fiscal Intermediary Shared System (FISS).
NCCI updates the PTP and MUE files on a quarterly basis. However, there may be instances in which a change is needed outside of those quarterly timeframes and a replacement file is necessary. CMS issued replacement files with the following changes:
- Dec. 7, 2022 - Replacement Files (1st quarter of 2023) - CMS issued replacement files for NCCI Procedure to Procedure (PTP) edits and updated for the January 1, 2023 files (PRA and OPH).
- Feb. 2, 2022 – Replacement Files (1st quarter of 2022) - CMS issued a second set of replacement files for NCCI Procedure to Procedure (PTP) edits for the Jan. 1, 2022 files.
- Dec. 14, 2021 – Replacement Files (1st quarter of 2022) – CMS issued replacement files for NCCI Procedure to Procedure edits (PTPs) and Medically Unlikely Edits (MUEs) for the Jan. 1, 2022 files.
The NCCI program is able to address general questions and concerns about the NCCI program and edits. Claim-specific inquiries must be directed to the MAC because NCCI edits are implemented by the MACs as part of routine claim processing. This includes appeals of NCCI-related denials; see Submitting an Appeal below.
You may submit inquiries about the NCCI program, including those related to NCCI (PTP, MUE, and Add-on Code) edits, in writing via email to NCCIPTPMUE@cms.hhs.gov .
**NOTE** Any submissions made to the NCCI program that contain Personally Identifiable Information (PII) or Protected Health Information (PHI) are automatically discarded, regardless of the content.
The NCCI program cannot answer questions outside of our scope or about other CMS programs. For example, we cannot answer questions about modifiers not associated with NCCI, Local Coverage Determinations, changes to code descriptors or status indicators.
Submitting an Appeal
Appeals must be submitted to your responsible MAC or QIC, not the NCCI Contractor. To file an appeal, please follow the instructions on the Appeals website. The NCCI contractor cannot process specific claim appeals and cannot forward appeal submissions to the appropriate appeals contractor.
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