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National Correct Coding Initiative (NCCI)

The Center for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payments in Medicare Part B claims.

 

Purpose

The purpose of the NCCI edits is to prevent improper payments when incorrect code combinations are reported.

 

Process

The NCCI consists of coding policies and edits. Providers report procedures and services performed on clients utilizing Healthcare Common Procedure Coding System (HCPCS) codes. These codes are submitted on claim forms to Fiscal Agents for payment. NCCI policies and edits identify procedures and services performed by the same provider for the same client on the same date of service.

 

Background

The NCCI was originally implemented in the Medicare program in January 1996 to ensure accurate coding and reporting of services by physicians. The coding policies of NCCI are based on coding conventions defined in the American Medical Association’s (AMA) Current Procedural Terminology (CPT) Manual, national and local Medicare policies and edits, coding guidelines developed by National societies, standard medical and surgical practice, and/or current coding practice.

The Medically Unlikely Edits (MUEs) were developed by CMS in 2007 to reduce the paid claims error rate for Medicare claims. The MUE for a HCPCS/CPT code is the maximum units of service that a provider is allowed to bill under most circumstances for a client on a single date of service. These edits are developed based on anatomic considerations, HCPCS/CPT code descriptions, CPT instructions, nature of services/procedures, nature of lab material under examination, and nature of equipment. The MUEs are not utilization guidelines, and providers should continue to only report services that are medically reasonable and necessary.


Provider Bulletins

 

NCCI Methodologies

·         NCCI edits or procedure-to-procedure edits that define pairs of HCPCS/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons; and

·         Medically Unlikely Edits (MUEs), or units-of-service edits that define for each HCPCS/CPT code the number of units of service beyond which the reported number of units of service is unlikely to be correct (for example, claims for excision of more than one gallbladder or more than one pancreas).  

 

 Quarterly Update

Providers are encouraged to monitor the Centers Medicare and Medicaid Services (CMS) website for updates to NCCI rules and guidelines. The updates for the procedure to procedure (PTP) and medically unlikely edit (MUE) files are completed quarterly with the next file update available April 2014. The CMS NCCI website is listed below.

 

 

For more information, including NCCI and MUE edits, please refer to the National Correct Coding Initiative in Medicaid website.


The Department of Health Care Policy and Financing is not responsible for the content of external websites.