Gastroenterology Coding Alert

Question: If I have a question about appealing a claim that has been denied due to a National Correct Coding Initiative (NCCI) edit, which agency is most appropriate to contact for a resolution?

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Answer: Though it may seem confusing, if you have a question about a specific claim, even if related to NCCI, you should direct it to your assigned Medicare Administrative Contractor (MAC), not an NCCI contractor.

“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,” the Centers for Medicare & Medicaid Services (CMS) says on its website.

Don’t forget: CMS developed and implemented NCCI to promote standardized — correct — coding of Medicare Part B claims. Its policies are based on coding conventions defined in the CPT^® code book as well as “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,” according to CMS. Note that many denials related to NCCI are due to not using correct modifiers like 59 (Distinct procedural service) to indicate the unusual circumstance that made dual reporting appropriate and being able to bypass the edit.