NCCI FAQs

I. Billing and Coding Advice

A. How do I obtain billing and coding advice from the NCCI Program?

The NCCI program contractor provides general information to the public regarding the NCCI program and edits. However, we do not provide specific billing or coding advice to providers/suppliers. Questions regarding specific claims should be addressed to your claims processing contractor (e.g., your Part A or B Medicare Administrative Contractor (MAC) or State Medicaid Agency). Providers/suppliers may also find it helpful to contact their national healthcare organization or the National Healthcare Organization (NHO) whose members commonly perform the procedure.

II. NCCI Policy Manual

A. 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 on the CMS NCCI web page at:

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index

B. 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

III. Medically Unlikely Edit (MUE)

A. What is a Medically Unlikely Edit (MUE)?

An MUE (Medically Unlikely Edit) is a unit of service 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 (DOS). The ideal MUE is the maximum unit of service 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 DOS edits.  (See separate FAQ for guidance on reporting medically reasonable and necessary services in excess of an MUE value.)  (See separate FAQ for information about DOS MUEs.)

B. How do I report medically reasonable and necessary units of service (UOS) 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 UOS in excess of an MUE value. Further information is available in MLN Matters MM8853 (PDF).

C. Are there Centers for Medicare & Medicaid Services (CMS) DOS Medically Unlikely Edits (MUEs) and Claim Line MUE for CPT/HCPCS codes?

Yes, there are both DOS and claim line MUEs. CMS publishes which codes have DOS and which codes have claim line MUEs.  (See separate FAQ for information about how claims are adjudicated).
The MUE files on the CMS NCCI web page display an “MUE Adjudication Indicator” (MAI) for each HCPCS/CPT code. An MAI of “1” indicates that the edit is a claim line MUE. An MAI of “2” or “3” indicates that the edit is a DOS MUE.  Further information is available in MLN Matters MM8853 (PDF).

D. How are claims adjudicated with Medically Unlikely Edits (MUEs)?

Medically Unlikely Edits (MUEs) are either claim line edits or 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 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 DOS MUE, all UOS for the HCPCS/CPT code reported by the same provider/supplier for the same beneficiary for the same DOS 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.

E. 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 claims data.

F. What is the difference between the Medically Unlikely Edit (MUE) tables for Outpatient Hospital (OPH) or Practitioner (PRA)?

There are separate MUE files, depending on the provider/supplier, for Practitioner use and Outpatient Hospital use. Further information may be found in the CMS NCCI “How to Use the NCCI Tools” document at the bottom of the NCCI web page under downloads, using the link below.

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd

G. 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) edit files and Medically Unlikely Edit (MUEs) files are updated at least quarterly. 

H. How long are the procedure to procedure (PTP) edits and Medically Unlikely Edits (MUEs) in the National Correct Coding Initiative (NCCI) valid?

The procedure to procedure (PTP) edit files and Medically Unlikely Edit (MUEs) files are updated at least quarterly. However, the National Correct Coding Initiative (NCCI) Policy Manual is updated annually.

NCCI PTP edits and MUEs for HCPCS/CPT codes apply to services reported by the same provider/supplier for the same beneficiary on the same DOS.

I. Has CMS published the Medically Unlikely Edit (MUE) values for Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes?

CMS publishes most MUEs for providers/suppliers on the NCCI web page. However, some MUEs are considered confidential by CMS and are not released. The public/confidential status of MUEs may change.

J. May an Advanced Beneficiary Notice (ABN) be utilized to bill the beneficiary for services denied due to a Medically Unlikely Edit (MUE)?

ABN issuance based on an MUE is NOT appropriate.  A denial of services due to an MUE is a coding denial, not a medical necessity denial. The presence of an Advance Beneficiary Notice (ABN) shall not shift liability to the beneficiary for UOS denied based on an MUE. If during reopening or redetermination medical records are provided with respect to an MUE denial for an edit with an MAI of “3”, MACs will review the records to determine if the provider/supplier actually furnished units in excess of the MUE, if the codes were used correctly, and whether the services were medically reasonable and necessary.  If the units were actually provided but one of the other conditions is not met, a change in denial reason may be warranted (for example, a change from the MUE denial based on incorrect coding to a determination that the item/service is not reasonable and necessary under section 1862(a)(1)). This may also be true for certain edits with an MAI of “1.” CMS interprets the notice delivery requirements under Section1879 of the Social Security Act (the Act) as applying to situations in which a provider/supplier expects the initial claim determination to be a reasonable and necessary denial. Consistent with NCCI guidance, denials resulting from MUEs are not based on any of the statutory provisions that give liability protection to beneficiaries under section 1879 of the Social Security Act.  Thus, ABN issuance based on an MUE is NOT appropriate. Further information is available in MLN Matters MM8853 (PDF).

K. How are Medically Unlikely Edits (MUEs) developed?

MUEs are developed based on HCPCS/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 judgment. MUE values are not utilization guidelines and do not represent UOS that may be reported without concern about medical review. Providers should continue to only report services that are medically reasonable and necessary. Providers may be subject to medical review of their claims even if they report UOS less than or equal to the MUE value for a code.

L. 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, they may email the CMS NCCI Mailbox at NCCIPTPMUE@cms.hhs.gov. The party should include, exact codes, an alternative MUE value, the rationale for the alternative MUE value and any supporting documentation. Please note that NCCI does not accept PHI/PPI and ask that you do not submit supporting documentation with patient information.

However, it is generally recommended that the party contact the national healthcare organization whose members perform the procedure. 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.

M. 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 including those related to MUE values for specific Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should be sent to the following email address:

NCCIPTPMUE@cms.hhs.gov

N. What determines the Unit of Service for a Medically Unlikely Edit (MUE)?

UOS are defined by the code descriptor (also referred to as the narrative description of the code).

Examples below show the HCPCS code, followed by the code descriptor, followed by the UOS.

  • J1100 “Injection, dexamethasone sodium phosphate, 1 mg” the UOS is 1 mg
  • J0670 “Injection, mepivacaine hydrochloride, per 10 ml” the UOS is 10 ml
  • J7180 Injection, factor xiii (antihemophilic factor, human), 1 IU, the UOS is 1 IU
  • 99292 “Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes” the UOS is 30 minutes

IV. Procedure-to-Procedure (PTP) Edits

A. What exactly does "Column 1" or “Column 2” mean in the Column 1/Column 2 correct coding edits table?

Detailed instruction regarding the use of “Column 1” or “Column 2” may be found in the “How to Use the NCCI Tools” booklet on page 7. This document may be found at the bottom of the NCCI web page under downloads.

B. How long are the procedure to procedure (PTP) edits and Medically Unlikely Edits (MUEs) in the National Correct Coding Initiative (NCCI) valid?

There is no set time period for which NCCI edits are valid.  Some edits may remain in place indefinitely. The procedure to procedure (PTP) edits and Medically Unlikely Edits (MUEs) may be updated at least quarterly.

C. Where can I find the rationale for why an edit is in place?

General information about edit rationale may be found in the NCCI Policy Manual, Chapter 1, Section J-T, available on the CMS NCCI web page at:

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index

Please follow the appropriate link on the NCCI web page under the downloads section.

Pages 5-11 of the How To Use The National Correct Coding Initiative (NCCI) Tools (PDF) booklet provides more detail about using the public PTP files.

D. 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, will both services be paid?

NCCI PTP edits for HCPCS/CPT codes apply to services reported by the same provider/supplier for the same beneficiary on the same DOS.

V. National Correct Coding Initiative (NCCI) Modifiers

A. What modifiers are allowed with the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits?

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include:

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

It is very important that NCCI PTP-associated modifiers only be used when appropriate. In general, these circumstances relate to separate patient encounters, separate anatomic sites, or separate specimens. (See subsequent discussion of modifiers in this section.) Most edits involving paired organs or structures (e.g., eyes, ears, extremities, lungs, kidneys) have NCCI PTP modifier indicators of “1” because the two codes of the code pair edit may be reported if performed on the contralateral organs or structures. Most of these code pairs should not be reported with NCCI PTP associated modifiers when performed on the ipsilateral organ or structure unless there is a specific coding rationale to bypass the edit. The existence of the NCCI PTP edit indicates that the two codes generally cannot be reported together unless the two corresponding procedures are performed at two separate patient encounters or two separate anatomic locations. However, if the two corresponding procedures are performed at the same patient encounter and in contiguous structures in the same organ or anatomic region, NCCI PTP-associated modifiers generally should not be used. Modifiers 59 or –X{EPSU} may be used only if no other appropriate modifier describes the service. CMS MLN SE1418 (PDF) provides more information on the appropriate use of modifiers 59 or –X{EPSU}.

B. How do I know which modifier to use to bypass an edit?

General information about NCCI-associated modifiers can be found in the NCCI Policy Manual, Chapter 1, Section E, available on the CMS NCCI web page at:

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index

C. Can modifiers 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 (CCMI) of "0."

D. If I have a situation where I think a modifier 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?

For more information on the use of modifiers please see the CMS Claims Processing Manual, Publication 100-04, Chapter 12 (PDF) and the NCCI Policy Manual for Medicare Services, Chapter 1, Section E.

Specific billing and reporting questions should be directed to your local Medicare Administrative Contractor (MAC) in writing.

E. 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 or other service, on the same day of service to indicate a "significant and separately identifiable" E&M service when appropriate. For additional information, please see the NCCI Policy Manual, Chapter 1, Section E. available on the CMS NCCI web page at:

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index

Please also refer to The Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.6, available at:

https://www.cms.gov/files/document/medicare-claims-processing-manual-chapter-12 (PDF)

F. How should modifiers 59 or –X{EPSU} be reported under the National Correct Coding Initiative (NCCI) program?

CMS MLN SE1418 (PDF) provides information on the appropriate use of modifiers 59 or –X{EPSU} .

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index

G. How should modifier 91 be reported under the National Correct Coding Initiative (NCCI) program?

Some PTP edits allow use of NCCI PTP-associated modifier 91 to bypass them if one or more of the individual laboratory tests are repeated on the same DOS. The repeat testing must be medically reasonable and necessary.

Based on the "Internet-only Manuals (IOM)," "Medicare Claims Processing Manual," Publication 100-04, Chapter 16, Section 100.5.1, the repeat testing cannot be performed to “confirm initial results; due to testing problems with specimens and equipment or for any other reason when a normal, one-time, reportable result is all that is required.”

VI. Published PTP and MUE Files

A. Where can I find prior year’s PTP and MUE files?

CMS posts only the current and one previous quarter’s PTP and MUE edit files. These files are available free to the public and may be found on the CMS NCCI web page located at:

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes

B. 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?

The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Part B claims. The coding policies are based on coding conventions defined in the American Medical Association's Current Procedural Terminology (CPT) Manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, and/or current coding practice. NCCI is responsible for developing, revising, and maintaining NCCI edits, responding to inquiries regarding the NCCI program, and promoting program integrity and compliance. Changes in the NCCI are the result of comments submitted to CMS. Prior to implementing new edits, CMS generally provides a review and comment period to representative national organizations that may be impacted by the edits. However, there are situations when CMS thinks that it is prudent to implement edits prior to completion of the review and comment period.  CMS Central Office evaluates the input from all sources and decides which edits are modified, deleted, or added each quarter.

C. 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 Medicare providers/suppliers to receive the National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits and published Medically Unlikely Edits (MUEs) is through the CMS NCCI web page. It is the responsibility of the entity billing Medicare to ensure that they bill correctly. Other government and private insurers may choose to adopt Medicare's NCCI methodologies. The application of Medicare’s NCCI methodologies and thereby the application of Medicare payment policies and rules to claims other than Medicare Part B claims may result in denials by other plans. Plans that voluntarily choose to adopt Medicare's NCCI methodologies should review their edits and consider deactivating individual edits that conflict with their own benefit and coverage determinations.

D. 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 updated at least quarterly.

E. 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 are not National Correct Coding Initiative (NCCI) edits.

 

Page Last Modified:
03/10/2020 02:32 PM