NCCI (National Correct Coding Initiative) is a program developed by CMS to promote correct coding and prevent improper payments in Medicare and Medicaid claims. It sets rules that identify and deny billing for procedures that shouldn't be reported together. The National Correct Coding Initiative (NCCI) has been one of Medicare's most advanced claim review systems. That's where the outsourced medical billing services come in whose experts are familiar with all the right modifiers to accurately perform NCCI edits. But before diving into the meat of this discussion, first, let's learn about NCCI edits in depth.

Defining Medicare NCCI Edits

CMS applied NCCI in the year 1996 to encourage accurate coding practices and avoid incorrect Medicare Part B payments. NCCI edits are coding guidelines created to avoid inappropriate coding and hence improper billing by identifying pairs of the CPT and/or HCPCS codes that cannot be reported together for the same patient, on the same service date by the same provider. The reasons behind NCCI edits are:

  • Preventing unbundling: It occurs when the providers submit multiple procedure codes where a single master code has to be utilized instead.
  • Identifying mutually exclusive procedures: These are procedures that cannot be performed together due to anatomical, temporal, or procedural conflicts.

Types of NCCI Edits

  • Procedure-to-Procedure (PTP) edits: PTP edits involve combinations of CPT/HCPCS codes which shouldn't be submitted together except when there are certain special situations.
  • Medically Unlikely Edits (MUEs): MUEs classify the maximum service units which a healthcare provider needs to bill for a single beneficiary on a single date of service. For example, an MUE could dictate that only one unit of an appendectomy procedure per patient per day, based on anatomical and clinical plausibility.

Why are the NCCI Edits Highly Complex?

  • Thousands of CPT/HCPCS codes interacting: The NCCI edits require an in-depth understanding of component-service relationships as well as mutually exclusive procedures. The PTP edits don't allow two current CPT or HCPCS codes when performed in conjunction unless a modifier (modifier 59 or X[EPSU]) justifies a distinct procedural context. Apart from that, MUEs also involve per-beneficiary, per-day unit threshold for CPT/HCPCS codes based on anatomical limitations, standard clinical practice and statistical outlier analysis.
  • Modifier usage interpretation: Correct modifier application (e.g., 25, 59, 91 and 76) required a nuanced understanding of the procedural context, temporal separation, diagnostic justification and anatomical specificity. Misuse of modifiers can result in denial, down coding or audit triggers.
  • Correlation of ICD-10-CM/CPT codes: The ICD-10-CM code needs to substantiate the CPT service in both guideline-defined indications and pathophysiological plausibility which is an extremely complex process.

How the Outsourced Medical Billing Services Help?

The third-party medical services have dedicated experts who can accurately perform the NCCI edits using:

Common NCCI-related modifiers: These experts have knowledge of modifier 59 which indicates that procedures or services not typically reported together were performed in a distinct and separate context. They know all the complex X modifiers which include:

  • XE: Separate Encounter
  • XS: Separate Structure
  • XP: Separate Practitioner
  • XU: Unusual non-overlapping service

Hence, using these modifiers, these outsourced experts can easily perform NCCI edits. Apart from that, they also use modifiers 25, 51 and 91 to prevent improper payment.

NCCI edits are essential to preserve the integrity of the healthcare reimbursement ecosystem and prevent procedural coding from devolving into disordered, non-evidence-based claims practice. But, as this process is highly complex, that's why it can be a feasible option to take the help of the outsourced medical billing services who know the proper modifiers to accurately perform NCCI edit. Hence, when your clinic properly ensures with the CPT/HCPCS guidelines, then they can expect fewer claim denials.