NCCI for Medicare

Medicare NCCI Manuals

  • CMS updates the NCCI Policy Manual for Medicare once a year. The NCCI Policy Manual should be used by Medicare Administrative Contractors (MACs) as a general reference tool that explains the rationale for NCCI edits. The most current policy manual, effective Jan. 1, 2022, was posted on Dec. 15, 2021. Additions and revisions to the manual are noted in red font. Additional prior versions of the National Correct Coding Initiative Policy Manual for Medicare Services are available in the NCCI Policy Manual Archive.
  • The most recent Medicare NCCI Correspondence Language Manual annual revision was posted on March 9, 2022. CMS wrote the manual and maintains it for use by the MACs to answer routine correspondence inquiries about the NCCI PTP and MUE edits. The general correspondence language paragraphs explain the rationale for the edits. The section-specific examples further explain 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 the manual for additional guidance about its use.
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Medicare National Correct Coding Initiative (NCCI) Edits

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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.

NCCI Implementation

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).

Replacement Files

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. 2, 2022 - The 1st Quarter 2023, Medicare NCCI PTP Edit Files and AOC Edit File posted on December 1, 2022 contain duplicate edits.  As a result, replacement files are necessary and will be issued as soon as technically possible, with an expected date of December 6, 2022.
  • 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.

Contact Information

The NCCI Contractor 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 or postal mail to:

National Correct Coding Initiative Contractor
P.O. Box 246
Pittsford, NY 14534

Fax #: 1.585.510.7234

**NOTE** Any submissions made to the NCCI contractor that contain Personally Identifiable Information (PII) or Protected Health Information (PHI) are automatically discarded, regardless of the content, in accordance with federal privacy rules the NCCI Contractor must comply with.

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.

Page Last Modified:
12/02/2022 01:00 PM