NCCI Edits Overview

Overview

This session explains NCCI (National Correct Coding Initiative) edits, their structure, application, and best practices for accurate and compliant medical coding in Medicare Part B billing.

Purpose and Design of NCCI Edits

• NCCI was developed by CMS to promote proper coding and reduce improper Medicare Part B claim payments.
• The initiative identifies code pairs that should not be billed together or limits the number of billable units for certain services.
• Aims to prevent duplicative billing and ensure medical appropriateness of rendered services.

Types of NCCI Edits

• There are two main types: Procedure to Procedure (PTP) edits and Medically Unlikely Edits (MUEs).
• PTP edits prevent inappropriate code pairs from being billed together.
• MUEs restrict the maximum units of a service that can be billed by the same provider for the same patient in one day.

Procedure to Procedure (PTP) Edits

• PTP edits indicate whether certain procedures can never or only sometimes be billed together.
• Some procedures (e.g., closure after surgery) are inherently included and not separately billable unless performed on a different site.

Medically Unlikely Edits (MUEs)

• MUEs define the maximum number of service units allowed per day based on clinical standards (e.g., only two knee replacements per day).
• Designed to flag questionable billing that exceeds typical medical necessity.

NCCI Edit Resources and Tools

• CMS provides quarterly-updated free NCCI edit tables and a policy manual on its website.
• Encoder software solutions can simplify access to NCCI data but may incur additional costs.
• Software highlights editable code pairings and when a modifier can make a pairing permissible.

Modifiers and Modifier Indicators

• Modifier indicators in NCCI tables show if and when a modifier can override an edit (0 = never, 1 = sometimes, 9 = not applicable).
• Modifier 59 indicates a distinct procedural service, allowing proper unbundling when warranted.
• Modifier 25 applies to significant, separately identifiable evaluation and management services on the same day as another procedure.
• Modifier 91 is used for repeat laboratory tests.
• Correct modifier use must be supported by documentation.

Using NCCI Edit Tables

• NCCI edit tables can be accessed and navigated using Excel features like “freeze panes” and “find” to locate relevant codes.
• The tables list code pairs, modifier indicators, effective dates, and rationales.
• The MUE files are similarly organized and show unit limitations per service code.

Tips for Compliance with NCCI Edits

• Always use the most current NCCI tables for the date of service you are coding.
• Cross-check encoder software results with official CMS data, as software may lag behind updates.
• Refer to the NCCI policy manual for guidance on when services can be unbundled.
• Ensure that accurate, documented coding minimizes risk of overpayment and supports compliance.

Recommendations / Advice

• Regularly update and reference NCCI edits and policy manuals to maintain compliance.
• Use free CMS resources for official guidance, and encoder software for efficiency, validating with CMS as needed.
• Support modifier use with strong documentation.

Questions / Follow-Ups

• Clarification requested on NCCI edits or coding scenarios can be left in the comments for further discussion.