If you don't know how to override edits, you could be leaving money on the table
National Correct Coding Initiative (NCCI) edits are part of your job every day, but do you really understand how they work and the risks involved? Check out this Q&A to make sure you're up to speed. 1. What Are
NCCI Edits ? NCCI edits are pairs of CPT Codes or HCPCS Level II codes that Medicare (and many private payers) will not reimburse if you code them together, except under certain circumstances. Medicare applies the edits to services billed by the same provider for the same beneficiary on the same date of service, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, NJ. 2. What Does 'Mutually Exclusive' Mean? NCCI contains two types of edits: mutually exclusive and "column 1/column 2" (previously known as "comprehensive/component" edits).
Mutually exclusive edits pair procedures or services that the physician could not reasonably perform at the same session on the same beneficiary, says Kelly Dennis, CPC, EFPM, owner of the consulting firm Perfect Office Solutions in Leesburg, Fla.
If you were to report two mutually exclusive codes for the same patient during the same session, Medicare would reimburse only for the lesser-valued of the two procedures.
3. How Do Column 1/Column 2 Edits Differ? Column 1/column 2 edits describe "bundled" procedures. That is, CMS considers the code listed in column 2 as the "lesser" service, which is included as a component of the more extensive column 1 procedure.
If you were to report bundled (column 1/column 2) procedures for the same patient during the same session, Medicare would reimburse only for the higher-valued of the two procedures.
For example, NCCI bundles 50220 (Nephrectomy, including partial ureterectomy, any open approach including rib resection) into 50230 (Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy). So, only the latter code gets paid. 4. Can I Override NCCI Edits? Yes, in certain circumstances you can override NCCI edits and achieve separate reimbursement for bundled codes. Follow these steps if you have distinct services:
Check the correct coding modifier indicator. Each NCCI code pair edit includes a correct coding modifier indicator of 0 or 1.
A 0 indicator means that you may not unbundle the edit combination under any circumstances, according to NCCI guidelines. An indicator of 1 means that you may use a modifier to override the edit if the procedures are distinct from one another, such as on a separate encounter on the same date, on a separate anatomical site, or for a separate indication.
Verify that the procedures are independent and distinct. [...]
