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NCCI

Overview

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Medicare Part B claims. Medicare carriers implemented NCCI payment methodology on January 1, 1996.

The CMS developed its coding policies based on the following:

  • Coding policy defined in the American Medical Association's CPT manual,
  • Coding based on national and local policies and edits,
  • Coding guidelines developed by national societies,
  • Through analysis of standard medical and surgical practices, and
  • By review of current coding practices.

The CMS annually updates the National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual should be utilized by providers as a general reference tool that explains the rationale for NCCI edits.

CMS NCCI Overview:
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd/NCCIEHOPPS/list.asp

The Patient Protection and Affordable Care Act (H.R. 3590) Section 6507 (Mandatory State Use of National Correct Coding Initiative (NCCI) required State Medicaid programs to incorporate "NCCI methodologies" in their claims processing systems by October 1, 2010. The purpose of the NCCI edits is to prevent improper payments when inappropriate code combinations or unlikely units of service are reported.

Medi-Cal will apply NCCI edits for claims processed on or after March 28, 2011 with dates of service on or after October 1, 2010.

NCCI edits consist of two types:

  1. Procedure-to-procedure(Column1/Column2) edits that define pairs of Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons; and
  2. Medically Unlikely Edits (MUE), which are units of service edits, that define for each HCPCS/CPT code identified, the allowable number of units of service; units of service in excess of this value are not feasible for the procedure under normal conditions (e.g., claims for excision of more than one gall bladder or more than one appendix).

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