Revenue Cycle Insider

Test yourself: Do you know which category of services aren’t covered by NCCI?

1. Question: What does NCCI stand for?

Answer: NCCI is the acronym for National Correct Coding Initiative, which is a program developed by the Centers for Medicare & Medicaid Services (CMS) to promote correct coding nationally for Medicare Part B claims. CMS says on the NCCI website that it owns NCCI and makes all the decisions about it, including developing coding policies based on the American Medical Association (AMA) Current Procedural Terminology (CPT^®) Manual, as well as local and national coding policies and code edits, national societies’ coding guidelines, analyses of standard medical and surgical practices, and a review of current coding practices.

2. Question: What kinds of service codes does NCCI cover?

Answer: The program covers several kinds of code edits: procedure to procedure (PTP), which has two provider-type choices; and medically unlikely edits (MUEs), which have three provider-type choices. PTP code pair edits cover outpatient hospital services and other facility services, including skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities, and others, and practitioner procedure edits, which apply to physician and ambulatory surgery center (ASC) claims.

Important: NCCI doesn’t apply to hospital inpatient prospective payment systems (IPPS).

MUEs, which are meant to reduce improper payment rates for Part B claims, include practitioner MUEs, durable medical equipment (DME) supplier MUEs, and facility outpatient hospital MUEs. CMS specifies that not all HCPCS/CPT^® codes have an MUE, but all claims submitted to Medicare Administrative Contractors (MACs) are tested against MUEs.

3. Question: How often is NCCI information updated?

Answer: The PTP and MUE files are updated at least quarterly, CMS says. If you’re using information you’ve previously downloaded, make sure you’re diligent about updating the files quarterly; otherwise you’ll be utilizing out-of-date and, thus, potentially inaccurate information. The effective date of an edit is listed in the file.

4. Question: How do I access up-to-date information if the edits are released so frequently?

Answer: You can find the information you need on the NCCI website. The most current code pair edits are available, and there are several resources, including the Medicare NCCI Policy Manual and the How to Use the Medicare National Correct Coding Initiative (NCCI) Tools booklet, which are updated annually. The files, while downloadable, are often large, so they are compressed into a .ZIP format so they download more quickly. CMS offers tips on how to navigate this format, if you look for the page “Help with File Formats and Plug-Ins.”

5. Question: Are the PTP code edit pairs cross-referenced when updated files are released?

Answer: The PTP codes will be published in a table, and you may already be familiar with the phrase “column 1 and column 2,” because that is how the code edit pairs have been organized historically. When you’re looking at the spreadsheet, you’ll need to “look both ways,” said Norma Panther, CPC, CDEO, CEMC, CHONC, CIRCC, CPMA, CCS-P, CHC, CIFHA, during her session “NCCI: More Than Pairs” at AAPC’s HEALTHCON 2024. Some of the edits are backward or unnecessary, Panther said, which may be because cross-referencing every code within the list would make the file absolutely humongous. So, if you’re looking up codes manually, you need to do the work of cross-referencing.

And don’t think too much about what’s there and what isn’t.

“You don’t have to understand why they made it an edit; you just have to work with the edit. Don’t try to figure out what CMS is thinking,” Panther recommended.

6. Question: What about modifiers?

Answer: Modifiers may be necessary, depending on the service. The following table has information, which applies to PTP code edit pairs, from the How to Use the Medicare National Correct Coding Initiative (NCCI) Tools booklet.

Note: This information, which is listed with the PTP code edit pairs, just lets you know whether you can use a modifier. The modifiers you use may be anatomic modifiers, global surgery modifiers, or other modifiers.

7. Question: Is it true that some MUEs are confidential?

Answer: Yes. CMS says that while most MUEs are visible to providers via the NCCI website, the agency considers some MUEs confidential and does not release them to the public. The confidential or public status of a MUE can change.

8. Question: When I’m looking at the updated files, how do I know what’s new?

Answer: Any updates will be displayed in red font instead of black. CMS and NCCI wants coders, billers, compliance staff, etc., to understand the NCCI program and to use the edits, so they try to make the information accessible. You’ll find resources to help, like Medicare Learning Network (MLN) bulletins, frequently asked questions (FAQs), and other means of assistance, many of which list tips to make the information more user-friendly.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC