NCCI FAQs

Number Question Answer
1 Why does it sometimes appear that CMS adds edits to the National Correct Coding Initiative (NCCI) in one version, and then in the next version changes or deletes those edits? Changes in the National Correct Coding Initiative (NCCI) are the result of comments submitted to CMS via Correct Coding Solutions LLC and CMS's written or telephone correspondence. Sometimes, new information is provided by a commenter which changes CMS' decision about the edit.
2 If I have a situation where I think one of the modifiers associated with the National Correct Coding Initiative (NCCI) should be used, is there someone who can tell me if I am using the modifier properly? Contact your local Medicare claims processing contractor, present the scenario and ask the question preferably in writing.
3 What is a Medically Unlikely Edit (MUE)? An MUE (Medically Unlikely Edit) is a unit of service (UOS) edit for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code for services rendered by a single provider/supplier to a single beneficiary on the same date of service. The ideal MUE is the maximum UOS that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. MUEs are adjudicated either as claim line edits or date of service edits. The MUE program provides a method to report medically reasonable and necessary UOS in excess of an MUE for MUEs that are adjudicated as claim line edits. (See separate FAQ for guidance on reporting medically reasonable and necessary services in excess of an MUE value.) If an MUE is adjudicated as a claim line edit or a date of service edit, UOS in excess of the MUE value may be paid during the appeal process. (See separate FAQ for information about date of service MUEs.)
4 How do I obtain the National Correct Coding Initiative (NCCI) Policy Manual? The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services may be obtained through the CMS website at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. The CMS website also contains a listing of the NCCI procedure to procedure (PTP) edits and published Medically Unlikely Edits (MUEs) which is available free to the public.
5 There are some software coding programs that already contain the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits and published Medically Unlikely Edits (MUEs). Do I still need to obtain the edits from the CMS website? At this time the official method for providers to receive the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits and published Medically Unlikely Edits (MUEs) is through the CMS website. It is up to the hospital and to the physician to be aware of the quarterly updates to the NCCI program.
6 What is the column 1/column 2 correct coding edit table? The column 1/column 2 correct coding edit table contains two types of code pair edits. One type contains a column 2 Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code which is an integral part of the column 1 HCPCS/CPT code. The other type contains code pairs that should not be reported together where one HCPCS/CPT code is assigned as the column 1 code and the other HCPCS/CPT code is assigned as the column 2 code. If two codes of a code pair edit are billed by the same provider for the same beneficiary for the same date of service without an appropriate modifier, the column 1 HCPCS/CPT code is paid. If clinical circumstances justify appending a National Correct Coding Initiative (NCCI)-associated modifier to the column 2 HCPCS/CPT code of a code pair edit, payment of both HCPCS/CPT codes may be allowed if the modifier indicator is "1".
7 How often are the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits and Medically Unlikely Edits (MUEs) updated? The National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits and Medically Unlikely Edits (MUEs) are usually updated on a quarterly basis. Note that the NCCI PTP edits are included in the Outpatient Code Editor (OCE). Under the hospital Outpatient Prospective Payment System (OPPS), the NCCI PTP edits are no longer one version behind.
8 How should modifier 91 be reported under the National Correct Coding Initiative (NCCI) program? Modifier 91 may be appended to laboratory procedure(s) or service(s) to indicate a repeat test or procedure on the same day when appropriate. This modifier indicates to the Medicare contractors that the physician had to perform a repeat clinical diagnostic laboratory test that was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain medically necessary subsequent reportable test values. This modifier must not be used to report repeat laboratory testing due to laboratory errors, quality control, or confirmation of results.
9 Do the critical care National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits apply to hospitals? Yes, the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits apply to hospital critical care services.
10 If I receive a bundling message that says something is included in a service billed on the same day and I do not find evidence of this edit in the latest version update of the National Correct Coding Initiative (NCCI), who should I ask about this denial?  Contact your local A/B Medicare Administrative Contractor (MAC) about other edits that may be in place on a national or local level which have nothing to do with the National Correct Coding Initiative (NCCI) edits.
11 How should modifier 59 be reported under the National Correct Coding Initiative (NCCI) program? Modifier 59 is used to indicate a "distinct procedural service". (See Modifier 59 article at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html for information about proper use of modifier 59.) Modifier 59 may not be appended to the evaluation and management (E&M) services Current Procedural Terminology (CPT) codes 99201-99499 or radiation treatment management CPT code 77427.
12 How should modifier 25 be reported under the National Correct Coding Initiative (NCCI)? Modifier 25 may be appended to an evaluation and management (E&M) code when reported with another procedure on the same day of service to indicate a "significant and separately identiable" E&M service when appropriate.
13 Can these modifiers that are associated with the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits be used with all the column 1/column 2 correct coding edits? No, there are some column 1/column 2 correct coding edits which CMS does not think would ever warrant the use of any of the modifiers associated with the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits. These code pairs are assigned a correct coding modifier indicator of "0".
14 Where can I find information about the National Correct Coding Initiative (NCCI) in the Medicare manuals? Information about the National Correct Coding Initiative (NCCI) can be found in the Internet-Only Manual, Publication 100-04, Section 20.9 of Chapter 23 of the Medicare Claims Processing Manual at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html
15 Are all the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits incorporated into the Outpatient Code Editor (OCE)? Most National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits are incorporated in the Outpatient Code Editor (OCE).
16 Are the procedure to procedure (PTP) edits and Medically Unlikely Edits (MUEs) in the National Correct Coding Initiative (NCCI) valid for a whole year?  No. The procedure to procedure (PTP) edits and Medically Unlikely Edits (MUEs) are updated on a quarterly basis. However, the National Correct Coding Initiative (NCCI) Policy Manual is updated annually.
17 If each of the Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) coded procedures listed in the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edit is performed by two different physicians in my clinic of different specialties, will both services be paid? From the National Correct Coding Initiative (NCCI) perspective, both will be considered for payment because the criteria that must be met for the NCCI procedure to procedure (PTP) edit to be applied is that the services are provided for the same beneficiary/patient, on the same date of service by the same performing provider.
18 Do I need to obtain each version update of the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits and Medically Unlikely Edits (MUEs) in order to manage our coding practices effectively and efficiently? Yes, there are a varying number of changes in every update. The volume depends on the number of comments processed, the number of edits reviewed, and/or the number of focused efforts for edit development.
19 Has CMS published the Medically Unlikely Edit (MUE) values for Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes? CMS publishes on its website most Medically Unlikely Edit (MUE) values. However, CMS does not publish MUE values for some codes. The MUE values for this latter group of codes are confidential information that should not be published by third parties who have acquired them.

MUE values are not utilization guidelines. Providers may be subject to a review of their claims by claims processing contractors, program safeguard contractors (PSCs), or recovery audit contractors (RACs) even if they report units of service less than or equal to the MUE value for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code.
20 May an Advanced Beneficiary Notice (ABN) be utilized to bill the beneficiary for services denied due to a Medically Unlikely Edit (MUE)? No, a provider/supplier may not issue an Advanced Beneficiary Notice (ABN) for units of service in excess of a Medically Unlikely Edit (MUE). Furthermore, if services are denied based on an MUE, an ABN cannot be used to shift liability and bill the beneficiary for the denied services. It is a provider/supplier liability.
21 What exactly does "column 1" mean in the column 1/column 2 correct coding edits table? If the two codes of a National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edit pair are reported for the same beneficiary by the same provider for the same date of service, the column 1 code is generally the only code eligible for payment. However, if the NCCI PTP edit allows use of NCCI-associated modifiers (i.e., modifier indicator of "1"), use of an appropriate NCCI-associated modifier allows both codes of the edit pair to be eligible for payment.
22 What does "column 2" mean in the column 1/column 2 correct coding edits table? If the two codes of a National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edit pair are reported for the same beneficiary by the same provider for the same date of service, the column two code is generally not eligible for payment. However, if the PTP edit allows use of NCCI-associated modifiers (i.e., modifier indicator of "1"), use of an appropriate NCCI-associated modifier allows both codes of the edit pair to be eligible for payment.
23 What modifiers are allowed with the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits? The following modifiers are allowed with the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits:
Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
Global surgery modifiers: 24, 25, 57, 58, 78, 79
Other modifiers: 27, 59, 91, XE, XS, XP, XU
Refer to Chapter I of the
National Correct Coding Initiative Policy Manual for Medicare Services for changes in this list of NCCI-associated modifiers.
24 Has the Centers for Medicare & Medicaid Services (CMS) implemented date of service (DOS) Medically Unlikely Edits (MUEs) for some codes? Beginning April 1, 2013, CMS began converting some claim line Medically Unlikely Edits (MUEs) to date of service (DOS) MUEs. The total units of service (UOS) from all claim lines for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code with the same date of service will be summed and compared to the MUE value. Claims denied based on DOS MUEs may be appealed using similar processes to claim line MUE denials. DOS MUEs are based on criteria including, but not limited to, anatomic considerations, CPT code descriptors or instructions, and nature of equipment or service. CMS publishes which codes have DOS MUEs. Since all UOS for a HCPCS/CPT code on all claim lines with the same date of service are summed, reporting additional UOS on separate claim lines with a HCPCS/CPT modifier will not result in payment of UOS in excess of the MUE value.
25 How are claims adjudicated with Medically Unlikely Edits (MUEs)? Medically Unlikely Edits (MUEs) are either claim line edits or date of service (DOS) edits. If the MUE is a claim line edit, each line of a claim is adjudicated against the MUE value for the Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code on that claim line. If the units of service (UOS) on the claim line exceeds the MUE value, all UOS 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 UOS for the HCPCS/CPT code reported by the same provider 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 UOS for the code on the current claim are denied.
26 What is the CMS Medically Unlikely Edit (MUE) program? The CMS Medically Unlikely Edit (MUE) program was developed to reduce the paid claims error rate for Medicare claims. MUEs are designed to reduce errors due to clerical entries and incorrect coding based on criteria such as anatomic considerations, Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code descriptors, CPT coding instructions, established CMS policies, nature of a service/procedure, nature of an analyte, nature of equipment, prescribing information, and clinical data.
27 How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit (MUE) value? For Medically Unlikely Edits (MUEs) that are adjudicated as claim line edits, each line of a claim is adjudicated separately against the MUE value for the code on that line. The appropriate use of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value. CPT modifiers such as 76 (repeat procedure by same physician), 77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), 91 (repeat clinical diagnostic laboratory test), and 59 (distinct procedural service) will accomplish this purpose. Modifier 59 may be utilized only if no other appropriate modifier describes the service. For MUEs that are adjudicated as date of service edits, units of service (UOS) in excess of the MUE value may be paid during the appeal process. (See separate FAQ for information about date of service MUEs.)
28 Is there an appeal process for units of service (UOS) denied based on Medically Unlikely Edits (MUEs)? Units of service (UOS) denied due to a Medically Unlikely Edit (MUE), whether a claim line MUE or date of service MUE, may be appealed. Appeals should be submitted to local contractors not the MUE contractor, Correct Coding Solutions, LLC. Contractors adjudicating appeals will determine whether (1) the appropriate Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code is reported; (2) the appropriate number of UOS is reported; and (3) whether the UOS reported are medically reasonable and necessary. Contractors may pay UOS in excess of the MUE value if the contractor determines that they are medically reasonable and necessary.
29 How were Medically Unlikely Edits (MUEs) developed? Medically Unlikely Edits (MUEs) were developed based on Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code descriptors, CPT coding instructions, anatomic considerations, established CMS policies, nature of service/procedure, nature of analyte, nature of equipment, prescribing information, and clinical data. All MUEs are evaluated with 100% claims data from a six month period.

Prior to implementation of the MUEs, the proposed edits are released for a review and comment period to the American Medical Association (AMA), national medical/surgical societies, and other national healthcare organizations, including non-physician professional societies, hospital organizations, laboratory organizations, and durable medical equipment organizations.

 
30 How do I request a change in the Medically Unlikely Edit (MUE) value for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code? If a provider/supplier, healthcare organization, or other interested party believes that a Medically Unlikely Edit (MUE) value should be modified, it may write Correct Coding Solutions, LLC at the address below. The party should include an alternative MUE value, the rationale for the recommended value and any supporting documentation. However, it is generally recommended that the party contact the national healthcare organization whose members perform the procedure prior to writing to Correct Coding Solutions, LLC. The national healthcare organization may be able to clarify the reporting of the code in question. If the national healthcare organization agrees that the MUE value should be modified, its support and assistance may be helpful in requesting the modification of an MUE value.

Requests for modification of an MUE value should be sent to the following:

National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907
FAX: 317-571-1745
31 How do I make an inquiry about the Medically Unlikely Edit (MUE) program other than about MUE values for specific Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes? Inquiries about the Medically Unlikely Edit (MUE) program other than those related to MUE values for specific Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should be sent to the following: NCCIPTPMUE@cms.hhs.gov

 
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01/23/2020 06:21 PM