General Question for the Week of April 29, 2024


What is the NCCI and how does it impact coding?


Also known as “unbundling edits,” the National Correct Coding Initiative (NCCI) is of major importance to hospitals that bill outpatient Part B services to the Medicare Part A/B MAC. Under the Outpatient Prospective Payment System (OPPS), each billable code is paid according to the APC group to which the service has been assigned. In order to assure proper payment for services, Medicare will process claims against the NCCI edits for Part A/B billing. The NCCI includes a series of “edits” that Medicare and other third-party payers use to screen claims for appropriate billing and payment. As part of the NCCI, carriers implemented procedure-to-procedure (PTP) edits in January 1996, medically unlikely edits (MUEs) in January 2007, and add-on code (AOC) edits in April 2013. A PTP edit identifies code pairs that are not separately billable when coded on the same date of service. An MUE identifies services with billed units greater than what is considered clinically appropriate. An AOC edit identifies a service that, with rare exception, should be performed in conjunction with another primary service by the same practitioner.

The PTP edits and MUE limitations are updated quarterly. The purpose of the edits is to ensure appropriate coding and billing of services and to guide proper payment of these services. The NCCI is updated through the course of the year and re-published each quarter with these changes. It is imperative that all practices and facilities required to bill under Medicare possess a current version of the material. The NCCI is Medicare’s most comprehensive bundling policy.

It is important to note that Medicare publishes two sets of NCCI edits on its website: one for hospital outpatient services used by Part A MACs and one for physicians used by Part B MACs. Guidelines for modifier application and coding pairs may differ between the OPPS facility and professional office setting due to the difference in services provided in each setting. In your facility, the modified subset of the NCCI may be referred to as the OCE file. The outpatient code editor (OCE) is utilized for processing of hospital claims to group APCs and determine payment for OPPS services. The OCE does not include NCCI edits for anesthesiology, evaluation and management (E/M), mental health, certain injections, wound closure by adhesive or computer- aided detection devices.

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