Nip Errors in the Bud with the NCCI and MUEs

Posted on 20 Jul, 2018 |comments_icon 0|By Elizabeth
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Backstory: Why NCCI was Started

The Centers for Medicare and Medicaid Services (CMS) is the agency responsible for the implementation of the National Correct Coding Initiative (NCCI), which was developed to encourage correct coding procedures on the national level and to reduce inappropriate coding that could lead to improper payment of Medicare Part B claims.

The coding policies and guidelines were developed based on the coding conventions outlined in the CPT® manual, national societies, national and local policies and edits, standard medical and surgical practices, and current coding practices.

How NCCIs and MUEs Work

On an annual basis, CMS updates the NCCI Coding Policy Manual for Medicare Services also known as the Coding Policy Manual. This manual is a valuable resource that provides an explanation into the rationale behind the NCCI edits.

Tip: Not all possible code combinations will be included in the NCCI!

There are many possible code combinations and it is not practical to expect NCCI to include every possible code combination in the edits. It is important for coders to review CPT® and HCPCS codes closely even if no edit appears with a code pair.

NCCI tables are updated on a quarterly basis and can be found at http://www.cms.gov. The tables are broken down by NCCI Procedure-to- Procedure (PTP) code pair edits and Medically Unlikely Edits (MUEs).

PTP Edits

PTP code pair edits are edits that are automated to prevent inappropriate payment when certain codes are billed together for Part B covered services. The user can select either practitioner or hospital depending on who they are billing for. See the table below for an example of an NCCI PTP code pair edit table.

Column 1/Column 2 Edits
Column 1 Column 2 *=In existence prior to 1996 Effective Date Deletion Date

*=no data

Modifier

0=not allowed

1=allowed

9=not applicable

PTP Edit Rationale
24940 96376 20090401 * 1 Standards of medical/ surgical practice
24940 96377 20170101 * 1 Standards of medical/ surgical practice
24940 97597 20050101 * 1 Misuse of column two code with column one code
24940 97598 20050101 * 1 Misuse of column two code with column one code
24940 97602 20060401 * 1 Misuse of column two code with column one code

Understanding the Sample NCCI PTP Edit Table

  • Column 1 in the example represents the payable code.
  • Column 2 contains the code that may or may not be payable with the Column 1 code.
  • The third column indicates if the code edit was in place prior to 1996.
  • The fourth column represents the effective date. (The dates are listed by year, month, and day.)
  • The fifth column indicates the deletion date, if applicable. (This date is also listed by year, month, and day.)
  • The sixth column indicates whether a modifier is applicable.
  • The seventh column provides the rationale behind the edit.

Modifier Indicators for Code Combinations

Modifiers may be added to HCPCS and CPT® codes if clinical circumstances/ documentation support the modifier. Never automatically add a modifier to a code simply because of an edit. There are circumstances where the documentation does not support the use of a modifier.

In an NCCI edit table, a modifier indicator of “0” means that a modifier is not allowed. When this indicator is present, under no circumstances should the code combinations be billed together.

Example: CPT® code 69990 (Microsurgical techniques requiring use of operating microscope) and 64430 (Injection, anesthetic agent; pudendal nerve), should never be billed together, per NCCI edits.

A modifier indicator of “1” means that a modifier is allowed with the code pair. A modifier indicator of “9” means that NCCI edits don’t apply to the code pair, and the edit was deleted retroactively.

Tip: Always refer to the medical record documentation before automatically adding a modifier to break an edit!

MUE Edits

A MUE refers to the maximum number of units of service that are allowed for a CPT® or HCPCS code. MUEs refer to units of service for the same date of service for a particular code and patient. These are included in the NCCI.

MUEs can be found on the CMS website where the entire MUE table can be downloaded into an Excel file. The user can select from three MUE code pair edit choices—practitioner, DME, or facility outpatient, depending on who they are billing for. See the table below for an example of an NCCI MUE code pair edits table.

Sample MUE Table
HCPCS / CPT® Code Practitioner MUE Adjudication Indicator MUE Rationale
93990 2 3 Date of Service Edit: Clinical Clinical: Data
94002 1 2 Date of Service Edit: Policy Code Descriptor/ CPT® Instruction
94003 1 2 Date of Service Edit: Policy Code Descriptor/ CPT® Instruction
94004 1 2 Date of Service Edit: Policy Code Descriptor/ CPT® Instruction

Understanding the Sample MUE Table

  • The first column contains the codes with a MUE value assigned.
  • The second column indicates the maximum number of units of service that a practitioner would be able to report under normal circumstances.
  • The third column describes the type of MUE.
  • The fourth column indicates the rationale behind the MUE.

Tip: A modifier may be necessary if reporting more than the allowed MUE for medically necessary reasons! An appeal may be necessary!

Watch out: A service may be denied based solely on PTP or MUE edits. Furthermore, it would be inappropriate for a provider to utilize an Advanced Beneficiary Notice of Noncoverage (ABN) in a case where a service is denied due to a NCCI or MUE edit. Utilizing the NCCI edit tool can prevent improper coding, billing, and reimbursement.

Learn More

Master self-audits, what to do with your findings, and how to get buy-in for remedial actions with TCI’s Master Auditing Basics 2018.

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Elizabeth


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