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National Correct Coding Initiative Edits

 

The National Correct Coding Initiative (NCCI) edits identify pairs of services that normally should not be billed by the same physician for the same patient on the same date of service. The NCCI edits are developed for use by the Centers for Medicare & Medicaid Services (CMS) in adjudicating Medicare claims, but they are also used by many private payers and Medicaid agencies. Furthermore, the NCCI edits frequently form the basis for proprietary claims software.

NCCI edits contain 1 of 2 types of edits—Mutually Exclusive Edits or Correct Coding Edits (formerly referred to as Comprehensive/Component Edits).

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1.  Mutually exclusive procedures are those procedures that cannot reasonably be performed together based on the code definitions or anatomic considerations. Therefore, Mutually Exclusive Edits are used to indicate 1 of 3 things: 1) the 2 codes cannot reasonably be done at the same session; 2) situations where 2 procedures representing 2 different methods to accomplish the same therapeutic result may have been employed and only the successful procedure should be reported; or 3) the reporting of an initial and a subsequent service together.

Mutually Exclusive Edits are set up so that the code with lower relative value units appears in column 1 as the payable service. If 2 codes of an edit are billed by the same provider for the same patient for the same date of service without an appropriate modifier, the column 1 code is paid. If clinical circumstances justify appending the appropriate modifier to the column 2 code, payment of both codes may be allowed.

2.  Correct Coding Edits are also divided into column 1 and column 2 procedures. However, the Correct Coding Edits include 2 types of edits: 1) column 2 (formerly referred to as Component) codes, which are considered an inherent part of the column 1 (formerly referred to as Comprehensive) codes, or 2) codes that should not be reported together for other reasons, such as misuse of a code.
If 2 codes of a Correct Coding Edit are billed by the same provider for the same patient on the same date of service without an appropriate modifier, the column 1 code is paid. If clinical circumstances justify the appending of the appropriate modifier to the column 2 code, payment of both codes may be allowed.
 
Each NCCI code pair is designated with a superscript 0 (zero), 1 (one), or 9 (nine). A 0 superscript appended to a code pair indicates that in no circumstances may a modifier be used to override that edit. Conversely, a 1 superscript appended to a code pair indicates that an appropriate modifier may be used to override the edit. Finally, a 9 superscript indicates that the code pair’s deletion date is the same as its effective date (ie, that particular edit was deleted before ever becoming effective).
 
The NCCI edits were developed by the CMS to promote correct coding by physicians and to ensure appropriate payment for Medicare services. The coding policies used in the creation of the edits are based on Current Procedural Terminology (CPT®) guidelines, national and local Medicare policies, analysis of standard medical and surgical practice, and review of current coding practice. In keeping with CPT guidelines, the NCCI edits allow override of some edits (ie, those with the superscript 1 appended) with use of the appropriate modifier. Following is a list of the modifiers that can be used to override NCCI edits:
 
  • E1 Upper left, eyelid
  • E2 Lower left, eyelid
  • E3 Upper right, eyelid
  • E4 Lower right, eyelid
  • FA Left hand, thumb
  • F1 Left hand, second digit
  • F2 Left hand, third digit
  • F3 Left hand, fourth digit
  • F4 Left hand, fifth digit
  • F5 Right hand, thumb
  • F6 Right hand, second digit
  • F7 Right hand, third digit
  • F8 Right hand, fourth digit
  • F9 Right hand, fifth digit
  • LC Left circumflex, coronary artery
  • LD Left anterior descending coronary artery
  • RC Right coronary artery
  • LT Left side
  • RT Right side
  • TA Left foot, great toe
  • T1 Left foot, second digit
  • T2 Left foot, third digit
  • T3 Left foot, fourth digit
  • T4 Left foot, fifth digit
  • T5 Right foot, great toe
  • T6 Right foot, second digit
  • T7 Right foot, third digit
  • T8 Right foot, fourth digit
  • T9 Right foot, fifth digit
  • 25 Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service
  • 58 Staged or related procedure or service by the same physician during the postoperative period
  • 59 Distinct (non-E/M) procedural service
  • 78 Return to the operating room for a related procedure during the postoperative period
  • 79 Unrelated procedure or service by the same physician during the postoperative period
  • 91 Repeat clinical diagnostic laboratory test
For overrides of Mutually Exclusive Edits or Correct Coding Edits, the appropriate modifier is always appended to the code that appears in column 2 because that is considered the bundled procedure. Furthermore, to append the appropriate modifier and override an edit, it is imperative that the conditions of that modifier are met. For example, to append modifier 25 to an E/M code that is part of an NCCI code pair, the E/M service must be significant enough to warrant the separate reporting of that code. The documentation should clearly reflect that, as well. And again, it should be noted that only NCCI edits designated with superscript 1 are eligible for such overrides.
 
NCCI edits are released 4 times per year, with each subsequent version replacing its immediate predecessor. Each version ends with a .0 (point zero), a .1 (point one), a .2 (point two), or a .3 (point three). Versions ending in .0 are effective from January 1 through March 31 of that year; versions ending in .1 are effective from April 1 through June 30 of that year; versions ending in .2 are effective from July 1 through September 30 of that year; and versions ending in .3 are effective from October 1 through December 31 of that year. For calendar year 2010, NCCI is using versions starting with 16 (sixteen). For example, the version for January 2010 is 16.0.
 
Specialty societies, including the American Academy of Pediatrics (AAP), have the opportunity to comment on new NCCI edits as they are proposed by the CMS. While the CMS is not always able to implement revisions based on specialty society comments, the NCCI edit development process does allow for an appeal process and remains the only coding edit program that actively encourages input from organized medicine.
 
Starting in September 2003, the CMS has released the NCCI edits free of charge on its Web site (www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage). Previously, they were only available via subscription through the US Department of Commerce. The online NCCI edits are searchable by procedure code ranges for simplified navigation.
 
For questions on NCCI edits, please contact the AAP Coding Hotline aapcodinghotline@aap.org.

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired. 
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