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National Correct Coding Initiative - NCCI & Medically Unlikely Edit - MUE

National Correct Coding Initiative - NCCI

National Correct Coding Initiative is developed by CMS to promote correct coding techniques in order to eliminate incorrect coding leading to inappropriate payment. NCCI edits are pairs of CPT or HCPCS codes that normally should not be billed by the same physician for the same patient on the same date of service.

NCCI includes two types of edits arranged by two sets of tables:

1. Comprehensive / component edits now commonly known as Column 1 / Column 2 codes respectively- identifies code pairs that should not be billed together because one service essentially includes the other. For example diagnostic colonoscopy CPT 45378 might not be billed along with Colonoscopy biopsy, CPT 45380 if both procedures are performed in the same site since CPT 45378 is column 2 code for CPT 45380 which is a column 1 code and so as per NCCI edits the payment would be made only for CPT 45380 and CPT 45378 would be denied with MRA reason code CO-125: Submission/billing error(s) (National Correct Coding Initiative (NCCI)).

It is obvious that CPT codes listed in the Column 1 set will have higher Relative Value Units (RVU) compared to the CPT codes listed as Column 2 in the Correct Coding edits and are non-payable if billed on the same day for the same beneficiary by the same provider.

2. Mutually exclusive edits – identifies code pairs that, for clinical reasons, are unlikely to be performed on the same patient on the same day i.e. a mutually exclusive edit might identify two different types of testing that yield equivalent results. For example as per CMS NCCI does not permit payment of CPT codes 84436 or 84479 with CPT code 84439 since Free thyroxine (CPT code 84439) is generally considered to be a better measure of the hypothyroid or hyperthyroid state than total thyroxine (CPT code 84436). If free thyroxine is measured, it is not considered appropriate to measure total thyroxine with or without thyroid hormone binding ratio (CPT code 84479).

The CMS NCCI Policy Manual for Medicare Services, Effective October 1, 2009 has been posted for all HCPCS / CPT codes in the path

http://www.cms.hhs.gov/NationalCorrectCodInitEd/

A complete list of Column 1 / Column 2 codes and Mutually Exclusive Edits for all HCPCS / CPT codes is available in the path

http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage

The Modifier indicators 0, 1 and 9 in the F column indicates

0 – There are no modifiers associated with NCCI that are allowed to be used with this code pair; there are no circumstances in which both procedures of the code pair should be paid.

1 – The modifiers associated with NCCI are allowed with this code pair when appropriate.

9 – This indicator means that NCCI edits do not apply to this code pair. The edits have been deleted for this code pair.

Medically Unlikely Edit (MUE)

CMS definition: 'An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service'. The adjudication system as per MUEs is against each line of a claim rather than the entire claim i.e. Each CPT and its modifier billed in a single line are separately adjudicated.

A quick reference of National Correct Coding Initiative (NCCI), Medically Unlikely Edit (MUE), Comprehensive Error Rate Testing (CERT) and Recovery Audit Contractor (RAC) is available at
http://www.cms.hhs.gov/MLNProducts/downloads/MCRP_Booklet.pdf

The CMS website contains the below sources of Information about NCCI and MUE

1) National Correct Coding Initiative Policy Manual for Medicare Services:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/

2) NCCI edits utilized for practitioner claims: http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/

3) NCCI edits utilized for outpatient hospital claims in the Outpatient Code Editor (OCE): http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEHOPPS/

4) NCCI Frequently Asked Questions (FAQ):http://www.cms.hhs.gov/NationalCorrectCodInitEd/

5) MUE Overview:http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage

6) MUE Frequently Asked Questions (FAQ):http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage

7) HCPCS/CPT codes with published MUE values in the Practitioner/DME Supplier MUE table: http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage

8) HCPCS/CPT codes with published MUE values in the Hospital Outpatient Services MUE table: http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage

9) Medicare Learning Network Publication: “Medicare Claim Review Programs: MUE, CCI, CERT, RAC”: http://www.cms.hhs.gov/MLNProducts/MPUB/itemdetail.asp?filterType=none&filterBDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS1209400&intNumPerPage=10

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