what exactly are ncci edits ncci is the national correct coding initiative and it was developed by CMS the centers for Medicare and Medicaid services to promote correct coding methodologies and reduce improper coding that could potentially lead to improper claim payment on Medicare Part B Services Medicare Part B covers your physician and provider stuff so things like your outpatient office visits or things like same day surgery so ncci is designed to reduce those improp payments and identify code sets of things that shouldn't be built correctly or shouldn't be buildt over a certain number of units in a day essentially it provides guidance to prevent duplicative billing and also make sure that services that are rendered are medically appropriate there are actually two main types of ncci edits we have the PTP or procedure to procedure which are services that one procedure shouldn't be built with the other procedure and then there are mues which are medically unlikely edits which are services that shouldn't be buildt over a certain amount and let's kind of break these down so procedure to procedure edits are saying that this procedure and this procedure either can never be built together or probably shouldn't be built together so for example if a patient is having a major surgery and the surgeon has to open them up included in that is that they're going to close them that's an inherent part of doing that open surgical procedure is that they have to close the patient so even though we have separate codes specifically for things like closures those are all included in that main surgery we would only build it out separate if there was some sort of separate area that was being closed mues are medically unlikely edits so things like the maximum amount of units that you would build for a service in a day for example you only have two knees so the maximum amount of knee Replacements one could assumably have in a day would be two now if you want to effectively use these ncci edits there are free resources available through CMS they give us all of the information we need right on their website with these ncci edit tables the tables are updated quarterly and they're broken down into chunks cuz it's a lot of information it's basically column listings of CPT codes and here's this CPT code and here's all the CPT codes it can't be buil with and then there's mu tables as well so again all the CPT codes the maximum number of units that would be built by the same provider in the same day now there's a lot of awesome software out there especially our encoder softwares find a code Cod select coder that can tell you all the information in regards to these ncci pairings and of course time is money so if they're saving you time and making this great resource though it's going to cost but you always have those free resources through CMS they might just not be as fancy and have all the bells and whistles as the encoder software plus with the software they also have to pay the AMA royalty fees which I'm I'm not going to get into a rant about the AMA today but the software makes it really easy so you can code your case you can get all the CPT codes you want to build type them into your encoder software and it will go yep you can build all of these together or oh these this one and this one you can build together but only if you can unbundle it with a modifier or you know these two you can never build together speaking of modifiers one of the key aspects of understanding n CCI edits is understanding the modifiers and modifier indicators so in the procedure to procedure edit tables there's a column that tells you if a modifier is or not allowed and what it does is have these modifier indicators so a modifier indicator of zero means no modifier can be used to unbundle these procedures you are never to put these procedures and build them together and a one means that you possibly can build them together in the right circumstances so it's a separate session it's a separate location there's something that's not within the standard realm of this procedure that says oh yeah these can definitely be build separately so it has to meet those appropriate circumstances and there is actually guidance in the ncci edit manual which we'll talk a little bit more about and then if there's a modifier indicator of nine it means that the edit is not applicable or a modifier is not needed so kind of going back to our closure example let's say the patient is coming in and they're having an appendectomy so included in that appendectomy is they're going to open the patient take the appendix out close the patient back up now let's say for example the patient had a totally separate laceration on their arm so in that case yeah we're going to build a separate closure for that arm it wasn't at all related to that appendectomy so it might say when we put those codes together yeah you can build these together with a modifier and when we look at our particular circumstances these were totally separate surgeries that are being done one is being done on the appendix one is being done on the arm we can unbundle those with a modifier and build them separately now of course they're going to have separate diagnosis codes as well but that modifier is what bypasses the system for the insurance company to kind of trigger to them and their edits in their system when they're processing the claim to let them know that this is separate and they should pay for both of these services in this particular case we would use a modifier 59 or one of the CMS xpu modifiers I have more about those modifiers in this video up here I'll also link it below if you want to check out the information on those unbundling modifiers now not all modifiers are unbundling modifiers meaning that not all modifiers can indicate oh yeah these are two procedures can be built together we're not trying to unbundle a surgical procedure we can build these two together so there's modifier 59 which means it is a distinct procedural service so one distinct procedure another distinct procedure again so the appendectomy would be one distinct procedure and the closure would be a separate distinct procedure totally different thing modifier 25 is a significant separately identifiable procedure done on the same day as an office visit so sometimes office visits are buil in with little minor procedures and we have to put a 25 on the office visit to let the insurance know though yes this was a different component not included in that office visit and then we have like modifier 91 which is for repeat laboratory work but with all things medical coding the use of those modifiers has to go back to is there appropriate documentation to support those services and the usage of those modifiers now let's actually take a look at the ncci tables I'm going to walk you through a little bit of what those look like so here we are at cms.gov and on cms.gov we're going to go under Medicare and then to coding and billing and National correct coding initiative edits when we look at the page for ncci edits there's a lot of cool information here specifically the how to use the ncci tools booklet that is a great resource but over here on the left hand side is where you're going to find those tables and the policy manual so very first here is that policy manual all the information about when we can and cannot unbundle services and over here is where we have the links to the table information so we have the mues and the ptps so down here on the left is our Medicare ncci procedure to procedure edits you will find the most recent quarters files here they are broken down by hospital and practitioner so if we're billing for the hospital versus billing for the practitioner and then the earlier versions are here as well when you look at these they are huge files so they're broken down into different segments there's four different files here just for the practitioner versions so say for example I want to check an ncci edit for a 99214 like what is included in the 99214 what can I cannot build with 99214 you're going to look at the ranges that are here for the code that you're going to look up and 99214 would fall in between these two codes the 62140 through our category codes over here so we're going to open up this file it's going to ask you to agree to the terms of service basically saying like they're not liable if things go wrong and once you open that it's going to come up in a zip file you're going to open up the zip file and it might take a little bit of time because it is a huge file so just be patient so here's all those column one versus column twos I was talking about the modifier columns and then there is actually rationale here as well one of the first things I like to do when I'm working with these files is I go ahead and I set up a freeze pane so that I can keep all of this information at the top because otherwise when you scroll you can't see what's on the top there so if we click right here and then go to view and then hit the freeze pane we can keep all that information as we're scrolling through now again this is a huge chunk of data now I'm sure a lot of you out there are better at Excel than I am and can probably figure out some better ways to manipulate through this data but for example let's say I'm going to my 99214 and I want to check that here what I usually do is I highlight the column A and again it sometimes takes a little while because it's just it's a lot of data and then if I do a contrl f while I've got column A highlighted I can type in 99214 and it will just search for the 99214 in column A and there we can see here's our 99213 is and then it starts getting into 99214 and then all of the things that are possibly included in the 99214 so here for example it tells us 99214 cannot be build with a 94002 here's the effective date for it it was January 1st of 2020 and there is a modifier indicator of zero meaning the modifier is not allowed you can never build these two procedures together or at least not build them together and get paid for them and for some of them it does give you the rationale as well it says here this one is because there is a CPT manual or CMS manual coding instruction saying what to do some of them it says misuse of column 2 and column 1 code standards of medical or surgical practice so they do provide some of the information at least a little bit you want to go back of course to that ncci edit policy manual if you're debating if you can or cannot unbundle those two codes if it says a modifier is allowed you want to make sure that it's allowed in the situation that is documented in the case you're looking at now we also have those mues those medically unlikely edits the ones that are more so geared towards units so here's our practitioner Services table we can download that again it's a zip file so we have to open up the files from the zip there's the comma separated value and the Excel document I want to open up the Excel one now this one is already freeze pain which I don't know why this one is and the larger file is not but if we go through it's again the list of all of the hips codes this one isn't separate files it's all just one together but for example we'll scroll down a bit so we'll have the code we'll have how many units we can build during that day there'll be the adjudicator information and then the rationale So based off of clinical data based off of the nature of the service anatomic considerations so this one just a little bit more straightforward I will see sometimes people will try to bypass these by billing them on different lines you know that's up to you and your situation and your philosophy of what you're doing if you want to do that a lot of these codes for example are skin related procedures leion removals graphs Etc and they do have some max number of units to them but you possibly could submit the documentation and build them out on separate lines and all kinds of stuff to attempt to get them paid staying compliant with ncci edits can seem a little bit daunting but here are some tips that you need to follow the first is to stay updated remember these edits are updated quarterly so you want to make sure that you are checking the most updated version based off of the date of service that you are coding for and if something seems fishy in your encoder software go back and double check it on that CMS stuff because sometimes those encoder softwares they miss something or they don't get updated appropriately and they don't reflect what's actually in the information that's given by CMS second is use the policy manual so there is an ncci edit policy manual you can find it on the CMS website I'll link it below as well it is the best resource you can find to defend yourself when you're looking at two procedures and going I don't think we should build these together or in this circumstance we can build these together it gives you those guidance of when it is and is not okay to unbundle service understanding and knowing how to appropriately apply these ncci edits is really critical for medical coding because we want to make sure that we're not accidentally taking any overpayments that we're being compliant and that we are being as accurate as possible to reflect the services that were provided and documented if you have any questions or comments about ncci please leave them in the comments below otherwise I will see you guys in the next video and until then just keep on coding on