NCCI Edit Resolution In Three Easy Steps
Lynn Thornton, RHIA, CCS
HIM IMEducation & Compliance Manager
Are you stymied by NCCI Edits? Do you really understand the meaning of modifier indicator (1) on the NCCI Procedure to Procedure (PTP) Edit Tables? What about the edit rationales? Are you able to navigate the tables and correctly assign CPT codes and modifiers with ease? If not, follow these three easy steps.
1. Recognize PTP modifier indicator (1). Despite the presentation of modifier indicator (1) = “allowed” on the NCCI (PTP) Edit Tables this is not the case. This modifier indicator is designating addition of a modifier is “allowed” only if certain parameters are met per the documentation.
2. If the PTP and MUE Edit Rationale is the source of your angst, meaning you don’t understand them, use the NCCI General Correspondence Language and Section Specific Examples (For NCCI Procedure to Procedure (PTP) Edits and Medically Unlikely Edits (MUE)). This resource will clarify what the edit rationale means which will assist you in resolving the edits. This resource provides guidance on the following PTP and MUE Edits Rationales:
* Standard preparation/monitoring services for anesthesia
* HCPCS/CPT procedure code definition
* CPT Manual or CMS manual coding instruction
* Mutually exclusive procedures
* Sequential procedure
* CPT “Separate procedure” definition
* More extensive procedure
* Gender-specific procedures
* Standards of medical/surgical practice
* Anesthesia service included in surgical procedure
* Laboratory panel
* Deleted/modified edits for NCCI
* Misuse of column two code with column one code
* Medically Unlikely Edits (MUE) (Units of Service)
* Deleted/modified edits for MUE
3. Use the NCCI Policy Manual to assist you if you are still uncertain regarding edit resolution. The policy manual addresses edits occurring on the NCCI edit tables and provides a background on why some codes are bundled. The policy manual also
addresses additional opportunity for reporting documented services and provides some modifier recommendations. The policy manual is divided up by CPT Chapter.
All coders must assure they are using the correct NCCI PTP Edit Tables. There are edit tables specific to “Hospitals” and another set of edits applicable to “Practitioners” available. An overview of the tables and the entities they are applicable to is provided below.
NCCI PTP Edit Tables
Tables Applicable to
NCCI Edits Practitioners These code pair edits are applied to claims submitted by physicians, non-physician practitioners, and Ambulatory Surgery Centers (ASCs) (provided the code is listed as one of the Medicare-approved ASC procedures).
NCCI Edits-Hospital Outpatient
Prospective Payment System
(PPS) This set of code pair edits is applied to the following Types of Bills (TOBs) subject to the Outpatient Code Editor (OCE): Hospitals (TOB 12X and 13X), Skilled Nursing Facilities (SNFs) (TOB 22X and 23X), Home Health Agencies (HHAs) Part B (TOB 34X), Outpatient Physical Therapy and Speech-Language Pathology Providers (OPTs) (74X), and Comprehensive Outpatient Rehabilitation Facilities (CORFs) (TOB 75X).
Additionally, there are MUE edit tables which address maximum units of services reportable for given services or procedures. There are not MUEs available for all CPT/HCPCS codes. An overview of the tables and the entities they are applicable to is provided below.
NCCI MUE Edit Tables
Provider Type Applicable to
Practitioner MUEs All physician and other practitioner claims are subject to these edits.
Durable Medical Equipment
(DME) Supplier MUEs These edits are applied to claims submitted to DME MACs. (At this time, this file includes HCPCS A-B, D-H, K-V codes in addition to HCPCS codes under the DME MAC jurisdiction.)
Facility Outpatient MUEs Claims for TOB 13X, 14X, and Critical Access Hospitals (85X) are subject to these edits.
Keep in mind the NCCI PTP, MUE Edit Tables and NCCI Policy Manual are updated on a quarterly basis and coders must assure they are using the correct edit set based on the date of service (DOS) for the encounter.