- Affordable Care Act (ACA)
- Beneficiary News
- Billing Tips
- Claim Form Updates
- CMC Submission
- Contract Drug List
- DUR Main Menu
- EPC Letters
- Fraud and Abuse
- LTC Rates Schedule
- Medi-Cal Comment Forum
- Medi-Cal Rates
- Medical Supplies Billing Requirements
- Medi-Cal & Telehealth
- Office of Health Information Technology
- Ordering, Referring and Prescribing (ORP)
- P/DCL List
- Provider Enrollment
- Provider-Preventable Conditions
- Quality and Accountability Supplemental Payment (QASP) Program
- Related Sites
- Suspended and Ineligible Provider List
- System Replacement Archives
- Technical Publications
- User Guides
A list of Frequently Asked Questions (FAQs) was developed to address common questions and concerns of Medi-Cal providers with the implementation of the National Correct Coding Initiative (NCCI). The FAQs will continue to be updated with new information as the NCCI implementation progresses.
For additional questions regarding NCCI, contact the Telephone Service Center (TSC) at 1-800-541-5555.
- What is NCCI?
A: The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate claims payment. The CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.
- What are NCCI Edits?
A: NCCI edits were developed to prevent improper payments when incorrect code combinations are reported. NCCI edits consist of two types:
- Procedure-to-procedure (column 1/column 2) edits: Define pairs of Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT-4) codes that should not be reported together. The purpose of these edits is to ensure the most comprehensive groups of codes are billed, rather than the component parts. Additionally this edit checks for mutually exclusive code pairs.
- Medically Unlikely Edits (MUEs): These edits compare the units of service billed on the claim against maximum limits set by CMS for each HCPCS or CPT-4 code. For example, a provider will not be reimbursed for removing more than one complete gall bladder or one appendix.
- When is Medi-Cal implementing NCCI edits on claims?
A: 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.
- Where can providers get more information on NCCI?
A: NCCI related information is located on the CMS website. In an effort to make the implementation of the NCCI understandable for Medi-Cal providers, the Department of Health Care Services (DHCS) has created a new NCCI webpage in the Featured area on the Medi-Cal website. The webpage includes CMS information and related links as well as Medi-Cal announcements related to NCCI and its implementation.
II. Billing/Claims Processing
- Are all providers affected by NCCI edits?
A: No, NCCI and MUE edits will not be applied to every Medi-Cal service and claim. Only claims for the following services will be subject to NCCI edits:
- Practitioner services
- Ambulatory surgical center services
- Outpatient hospital services
- Supplier claims for Durable Medical Equipment
- How are NCCI edits going to affect claims processing and payment?
A: In the Medi-Cal processing system, claims will process for NCCI edits before being processed for Medi-Cal edits. NCCI Procedure to Procedure and MUE edits are applied to services performed by the same provider for the same recipient on the same date of service. A Treatment Authorization Request (TAR) may be allowed to override an NCCI Medically Unlikely Edit. That is, where medical justification is currently allowed to override a Medi-Cal edit, this justification may be considered for a quantity greater than that allowed by the MUE. Procedure to Procedure edits are applied to all services with the same date of service whether the services are submitted on the same or different claims. MUE edits are applied separately to each line of a claim.
- What are Column 1/Column 2 edits?
A: The column 1/column 2 correct coding edit table contains two types of code pair edits, as follows:
Comprehensive : The code in column 1, which usually represents the more significant (comprehensive) procedure, is compared to the code in column 2, which is considered a subpart (component) of the service in column 1. Claims submitted for reimbursement of both codes without justification will be denied because the service represented by the code in column 1 includes the service represented by the code in column 2.
Mutually Exclusive : The code in column 1 is compared to the code in column 2. The claim is denied because it is unlikely that both services would be rendered to the same recipient, by the same provider on the same date of service (for example, a hysterectomy and vasectomy).
The column 1/column 2 table has an additional function, to indicate whether the use of NCCI-associated modifiers are allowed in order to bypass the NCCI edit. If the modifier indicator is “1”, providers may use an NCCI-associated modifier to show their claim is an exception to usual practices and the claim should be reimbursed. For example a physician performing two significant, separately identifiable Evaluation & Management (E&M) services might enter modifier 25 on the claim and provide documentation showing why the two E&M procedures were medically necessary.
Column 1 Column 2 Modifier
12001 64450 0 12001 G0168 1 12001 93010 1
- Where can providers find all the NCCI edits?
A: ZIP (compressed) files showing NCCI and MUE edits are available on the CMS website. Additionally, charts showing NCCI-related edits, including MUEs, mutually exclusive edits and column 1/column 2 edits for HCPCS Level II codes, are included in the back of the 2011 HCPCS code book.
- Are there new billing practices involved with Medi-Cal’s implementation of NCCI?
A: CMS has identified a set of modifiers to facilitate NCCI claims processing. For claims where multiple encounters or other circumstances could appear to fail NCCI edits and lead to inappropriate claim denial, providers can use the following modifiers to accurately define the service encounter. (An asterisk indicates the modifier will be added for Medi-Cal use):
Modifier Description (see code book for full description)
E1 – E4 Anatomic areas of the eye lid F1 – F9, * FA * Hands and digits LC, * LD, * RC * Anatomic areas of the coronary arteries LT, RT Left and right sides of the body T1 – T9, * TA * Foot and toes
Global Surgery Modifiers
25 Separate Evaluation & Management (E&M) on the same day 58 Staged or related procedure by same physician during postop period 78 Unplanned return to the operating/procedure room 79 Unrelated procedure or service during postop period
59 Distinct procedural service 91 * Repeat clinical diagnostic laboratory test
Medi-Cal allows up to four modifiers on a single claim line for both the CMS-1500 and UB-04 claim forms. These are the claim types affected by NCCI. The NCCI-associated modifier must be billed in one of the four modifier positions. Multiple NCCI-associated modifiers cannot be included on the same claim line.
- Are TARs affected?
A: A Treatment Authorization Request (TAR) may be allowed to override an NCCI Medically Unlikely Edit. That is, where medical justification is currently allowed to override a Medi-Cal edit, this justification may be considered for a quantity greater than that allowed by the MUE.
TARs must reflect the same modifier-use as the claim, that is, more than one NCCI-associated modifier must not be used on the same line. In order to assure proper claims adjudication when TARs are used, TARs should not be submitted with more than one NCCI-associated modifier (for example, modifiers LT and RT) on the same claim line.
- When will claims start being subjected to NCCI edits?
A: Effective March 28, 2011, claims processed with dates of service retroactive to October 1, 2010, will have National Correct Coding Initiative (NCCI) edits applied. Claims with dates of service on or after October 1, 2010, which were processed prior to the implementation of NCCI on March 28, 2011, will not be reprocessed to enforce NCCI edits; however, claims processed or reprocessed on or after March 28, 2011 with dates of service on or after October 1, 2010 will be subject to NCCI claim edits.
III. Claims Follow Up
- How do providers correct denied claims as a result of NCCI edits?
A: There is no claim processing system override for NCCI edits. Claims that fail the NCCI edits will be denied and returned to the provider, who may submit an appeal for reconsideration of payment in excess of the normally allowed amount. Claims Inquiry Forms (CIFs) must not be submitted for claims denied as a result of NCCI edits.
- How do providers avoid having claims denied with RAD code 9941 when surgeon and outpatient facility are billing supplies for the same procedure? (Code 9441: NCCI column 2 procedure code is not allowed when column 1 procedure has been paid)
A. Remittance Advice Details (RAD) code 9941 or voided with void 525 are due to National Correct Coding Initiative (NCCI) edits in the Medi-Cal claims processing system (Column 1/Column 2 edits).
A likely cause is that the facility and surgeon are entering different procedure codes on their claims. One provider may have submitted the code for a slightly different, related procedure. In this case one procedure will be tagged by the system as a medically unnecessary service.
The fix for this conflict is for both providers to use the same service code with unique modifier(s) appropriate to their provider type.
Medi-Cal has decided that to facilitate processing of procedure code/supplies modifier claim lines, providers may enter NCCI-associated modifier 59 (distinct procedural service) on the claim line. Modifier 59 must be entered on the claim line after surgical modifiers and any required modifiers, such as UA or UB.
- How do providers avoid having claims denied with RAD code 9940 when billing with modifiers LT and RT? (NCCI quantity billed is greater than the allowed MUE (Medically Unlikely Edit) quantity.)
A. The claims processing system disallows modifiers LT and RT on the same claim line. If the claim is within billing time limits, resubmit the claim with modifiers on seperate claim lines. If the claim is beyond the six month claim billing limit, the provider should submit an appeal.
- How do providers avoid having RAD code 9941 and void 525 appeals denied for a lack of sufficient information?
A. In general, claims denied due to RAD code 9941 or void 525 may be corrected by submitting an appeal that includes the correct procedure code and modifiers, including NCCI-associated modifiers as needed to clarify situations that the claims processing system may see as already paid by another claim or medically unnecessary.