Orthopedic Coding Alert

Question: Coders are supposed to learn the National Correct Coding Initiative (NCCI) quarterly edits each time they are released. However, I haven’t consulted NCCI for a year or more, and I was never that confident in my knowledge of the concept. Can you give me a quick rundown about the latest edits, along with a refresher on some of the major NCCI concepts?

California Subscriber

Answer: The Medicare National Correct Coding Initiative (NCCI) released its latest quarterly updates in June, with an effective date of July 1, 2020. For your purposes, you’ll want to focus on the Medicare Procedure-to-Procedure (PTP) NCCI edits for practitioners. If you haven’t read them yet, you should also review the written NCCI guidelines, which are updated around October annually.

As there are hundreds of additions/deletions in the update, it would be impossible to delve into the specifics of each edit. Coders should check out the list themselves; then, check the list against the codes you use in your work, and make any necessary adjustments. The NCCI edits are at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes. Scroll down to “Quarterly Additions, Deletions, and Modifier Indicator Changes to NCCI PTP Edits for Physicians Practitioners Effective July 1, 2020-posted June 1, 2020,” and download the file.

It’s also important to make sure that the NCCI edits have been implemented by payers before you file using the new edit rules. The implementation date is officially July 1, but not every payer is right on time with every update. According to Medlearn Matters, the NCCI effective date is July 1, but the implementation date when payers have to have systems ready is July 6. Hopefully, every payer is up to speed with the new NCCI edits by now, but you never know.

Modifier indicators: Another concept you need to grasp when reading NCCI edits is that of modifier indicators. In the latest NCCI edits, almost all of the additions are accompanied by a modifier indicator of 1 (allowed), meaning you can unbundle the services and code them separately using one or more of the modifiers Medicare accepts for bypassing edits, such as modifier 59 (Distinct Procedural Service) in certain situations.

The modifier indicator of 1 has flummoxed many a coder, warns Jean Acevedo, LHRM, CPC, CHC, CENTC, president and CEO of Acevedo Consulting Incorporated in Delray Beach, Florida. “For the many coders and billers who have not been formally educated on the NCCI edits, that see a modifier is allowed; this is so misleading.” She feels that there should be information explaining that an indicator of 1 means unbundling the codes with a modifier “is allowed if appropriate and the documentation supports it.”

“This lack of clarity in how the [modifier indicator] concept is presented is quite possibly the main reason for improper [NCCI coding],” according to Acevedo. “After all, when these individuals see the doctor is coding two procedures that have a NCCI edit, but the instructions say “modifier allowed,” why wouldn’t they just add a modifier to get both services paid?”

This list of NCCI edits includes a single addition with a modifier indicator of 0 (not allowed), meaning you cannot unbundle this code pair for any reason.

There are also several edits that sport an indicator of 9 (not applicable), meaning that the edit will be deleted retroactive to its creation, as if it never existed.

Finally, remember the meaning of each column in the NCCI edits. Column 1 lists the comprehensive (or major) code, and column 2 lists the secondary (or component) code. This means that if both services are performed, the column 1 code would be payable if it’s a covered code. The column 2 code is only payable when the edit has a modifier indicator of 1 and the encounter meets the definition of distinct procedural service. Also, you must append one or more NCCI PTP-associated modifiers to bypass the edit.