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NC Department of Health and Human Services
NC Division of
Medical Assistance
 
 

Correct Coding - NCCI and Additional Edits

National Correct Coding Initiative (NCCI)

*Please see the information below regarding “Additional Correct Coding Edits Implementation".


Overview

In March 2010, the Patient Protection and Affordable Care Act of 2010 [(H.R. 3590) Section 6507 (Mandatory State Use of National Correct Coding Initiative (NCCI)] as amended by the Health Care and Education Recovery Act of 2010 (P.L. 111-152), together referred to as the Affordable Care Act (ACA) was approved.  This legislation requires all state Medicaid programs to incorporate “NCCI methodologies” in their claims processing systems.   States have until March 31, 2011, to comply the NCCI mandate. 

NCCI is a program developed by CMS that consists of coding policies and edits that identify procedures and services performed by the same provider on the same date of service.  This program has been in existence for Medicare since 1996, and is now being applied to Medicaid services.


NCCI Components

There are two main components of the CMS mandate:

  • NCCI – procedure-to-procedure edits for practitioners, ambulatory surgical centers, and outpatient hospital services that define pairs of HCPCS/CPT codes that should not be reported together.
  • Medically Unlikely Edits (MUE) – these are units-of-service edits for practitioners, ambulatory surgical centers, outpatient hospital services, and durable medical equipment.  This component defines for each HCPCS/CPT code the number of units of service that is unlikely to be correct. (e.g., claims for excision of more than one appendix or more than one hysterectomy).

The purpose of the mandated edits is to prevent improper payments when a provider submits incorrect code combinations or to avoid payments of units in excess of what is medically unlikely.


NCCI Implementation

To comply with the NCCI mandate, DMA will implement the two main components by March 31, 2011. The potential exists that these edits may impact claims payments for practitioners, ambulatory surgical centers, outpatient hospital services (only for drugs, high-tech images, ultrasounds, and labs as they are billed at a CPT/HCPCS code level), and durable medical equipment. As DMA progresses through the NCCI implementation, additional information will be published in the Medicaid Bulletin.

New CCI and MUE EOBs will be reported on the provider’s Remittance and Status (RA) Report.


Additional Correct Coding Edits Implementation

DMA plans to implement additional correct coding guidelines to enhance our current claim processing system.  These new correct coding guidelines and edits will be nationally sourced by organizations such as the Centers for Medicare and Medicaid Services (CMS) and The American Medical Association (AMA).  These edits will identify any inconsistencies with CPT, AMA, CMS and/or DMA policies and will deny the claim line. 
For example, the edits will ensure that:

  • The appropriate procedure code is utilized based on age and gender of the patient. 
  • If a procedure code is submitted that requires a primary procedure code, DMA will verify that the primary procedure code has been submitted. 
  • Procedure codes are billed in the appropriate place of service as defined by AMA and/or CMS.  For example, certain procedure codes are not permitted to be performed outside of an inpatient setting.
  • Obstetric services including antepartum care, delivery, and postpartum care are billed appropriately according to CMS guidelines and DMA policy.
  • The appropriate Evaluation and Management (E & M) codes are utilized for new patients and established patients. 
  • Certain services related to a surgical procedure are included in the payment of the global surgery package.  These services would include E & M and related surgical procedures performed by the same physician for the same patient.
  • Duplicate services are not submitted for the same provider, same patient for the same date of service.   
  • Descriptions of Planned Additional Correct Coding Edits

DMA will notify providers through the Medicaid Bulletin and other means when these additional correct coding edits are being implemented.  


Additional Information

Information regarding NCCI implementation is available in the Correct Coding Initiative Fact Sheet (PDF, 60 KB) and in the March 2011 Seminar/Webinar Presentation (revised 3/21/2011) (PDF, 2.5 MB). Click here for information on adjusting the number of units for submitted claims.

Providers are encouraged to review published bulletin articles for information and updates on the status of the project and for information on provider training opportunities.

National Correct Coding Initiative

Information pertaining to the NCCI mandate is also available on the CMS Medicaid NCCI Coding web page. The NCCI State Medicaid Director letter and the Frequently Asked Questions documents contain valuable information regarding this mandate. 

The comprehensive list of codes can be downloaded from the CMS NCCI and MUE Edits web page. The list is available by type of provider or service.

Additional Correct Coding Edits

  • Additional Correct Coding Edits - May 2011
  • Place of Service
    • Suspended Implementation of Place of Service and Inpatient Only Services Correct Coding Edits, Revised Additional Correct Coding Edits Timeline - July 2011
    • Implementation of Additional Correct Coding Edits:  Place of Service and Inpatient Only Services - June 2011
  • Implementation of Additional Correct Coding Edits:  Age/Gender and Add-on Codes - June 2011
  • Global Surgery
    • Implementation of Additional Correct Coding Edits: Global Surgery and Evaluation and Management Codes - September 2011
    • Implementation of Additional Correct Coding Edits:  Global Surgery and Evaluation and Management Codes - June 2011
  • New Visit and Obstetric Care
    • Implementation of Additional Correct Coding Edits: New Visit and Obstetric Care - October 2011
    • Revised Timeline for the Implementation of Additional Correct Coding Edits: New Visit and Obstetric Care - September 2011
    • Implementation of Additional Correct Coding Edits: New Visit and Obstetric Care - August 2011
  • Professional Duplicates
    • Implementation of Additional Correct Coding Edits: Professional Duplicates - June 2012
    • Implementation of Additional Correct Coding Edits: Suspended Implementation of Professional Duplicate Edits - March 2012  
    • Implementation of Additional Correct Coding Edits: Professional Duplicates - February 2012
    • Implementation of Additional Correct Coding Edits: Professional Duplicates - January 2012
    • Implementation of Additional Correct Coding Edits: Professional Duplicates - December 2011
    • Implementation of Additional Correct Coding Edits: Professional Duplicates - November 2011
  • Facility Duplicates
    • Implementation of Additional Correct Coding Edits: Facility Duplicates--December 2012
    • Implementation of Additional Correct Coding Edits: Suspended Implementation of Professional Duplicate Edits - March 2012  
    • Implementation of Additional Correct Coding Edits: Facility Duplicates - February  2012 
    • Implementation of Additional Correct Coding Edits: Facility Duplicates - January 2012

       

 

 

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