NCCI edits

NCCI edits are the coding rules behind most bundling denials. CMS developed the National Correct Coding Initiative to promote correct coding on Medicare Part B claims, and it publishes two sets of edits. Procedure-to-procedure (PTP) edits list pairs of HCPCS and CPT codes that should not be paid together for the same patient on the same date by the same provider, to prevent improper payment when incorrect code combinations are reported. Medically unlikely edits (MUEs) set the units of service that a code would normally not exceed. Both files are updated quarterly, and Medicaid runs its own NCCI program with its own edit files.

Each PTP pair has a column one code, a column two code and a modifier indicator. CMS’s modifier booklet explains the indicator: with an indicator of 0 the codes are never paid together, and the column two code is denied; with an indicator of 1 the pair can be paid together in limited circumstances when an NCCI-associated modifier such as 59, XE, XP, XS or XU is supported by the documentation. On the remittance these denials usually arrive as CARC 97 (the payer treats it as already paid inside another service on the claim) or CARC 236 (the combination is not compatible under NCCI).

The mistake is treating the edit as the payer’s opinion. The pairs are published, free and searchable, and a scrubber can check every claim against the current quarter’s file before it goes out. Do that, and then decide from the note whether a modifier is honest or whether the second line should not be billed.