Part B Insider (Multispecialty) Coding Alert

Question: The Correct Coding Initiative (CCI) baffles me; I have a lot of trouble with the terminology. For instance, what is the difference between mutually exclusive edits, and medically unlikely edits?

Alabama Subscriber

Answer: Though they may sound similar on the surface, CCI identifies them as completely different kinds of edits.

CMS defines CCI Procedure-to-Procedure (PTP) code pair edits — Column 1 and Column 2 edits — as “automated prepayment edits that prevent improper payment when certain codes are submitted together.” In other words, the Column 2 code is a procedure that is a component part, or bundled into, the more comprehensive service described by the Column 1 code.

CCI provides three indicators for these edits:

• 0 (Not allowed): There are no modifiers associated with CCI that are allowed to be used with this PTP code pair; there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider.
• 1 (Allowed): The modifiers associated with CCI are allowed with this PTP code pair when appropriate.
• 9 (Not applicable): This indicator means that an CCI edit does not apply to this PTP code pair.

You can find more in-depth clarification on these indicators at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf.

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