Besides understanding the assignment of diagnoses and procedure codes, candidates sitting for the certified coding specialist (CCS) and CCS-P (physician-based) exams are expected to understand how these codes interact with other components in the billing process. This column will provide an overview of the National Correct Coding Initiative (NCCI) edits related to CPT and HCPCS coding for hospital outpatient and physician service. Reimbursement will be affected on claims that incur these edits.
There are two sets of NCCI edits, one set is utilized for hospital reporting and the other set for physician reporting. The first set is included in the Outpatient Code Editor (OCE) and is used by Medicare fiscal intermediaries (FIs) and Medicare Administrative Contractors (MAC) to process hospital outpatient claims. The other set of NCCI edits are used by Medicare carriers and MACs to process professional claims. It is important to recognize these edits apply to services performed by the same provider on the same date of service to the same patient.
The NCCI was developed by the Centers for Medicare and Medicare Services (CMS) to:
• Prevent payments from being made due to inappropriate CPT and HCPCS code assignment;
• Eliminate unbundling of services;
• Detect incorrect or inappropriate reporting of combinations of CPT and HCPCS codes; and
• Curtail improper coding practices that lead to inappropriate increased payment.
NCCI edits are performed on every possible pairing of CPT and HCPCS codes. They were developed and continue to be enhanced using:
• 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 practice; and
• Review of current coding practice.
The NCCI editor consists of two tables of CPT and HCPCS codes containing Mutually Exclusive edits and Column 1/Column 2 edits. Each table consists of code pairs arranged in two columns. Column 1 indicates the correct code, and Column 2 indicates the incorrect or inappropriate code in relation to the Column 1 code. Medicare pays the Column 1 code and denies payment for the Column 2 code.
Mutually Exclusive Procedures: The mutually exclusive table identifies procedures that cannot be reasonably performed on the same day. Many of these edits are based upon the definition of the component that differentiates one code from the other. For example:
• 25111 Excision of ganglion, wrist (dorsal or volar); primary
• 25112 Excision of ganglion, wrist (dorsal or volar); recurrent
These two codes are considered mutually exclusive because the ganglion must be defined as either primary or recurrent, but cannot be considered both.
Column 1/Column 2: The Column 1/Column 2 edit table contains two types of code edits. The first type contains comprehensive CPT codes that include services that are separately identifiable by other CPT codes. When the comprehensive procedure is reported, the component services should not be reported separately.
The second type contains code pairs that should not be reported together for other reasons. An example of this includes reporting two codes that essentially describe the same service with one code being more specific for the situation. For example:
• 28285 Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy)
• 28024 Arthrotomy, including exploration, drainage or removal of loose or foreign body; interphalangeal joint
The hammertoe repair code (28285) is considered the comprehensive procedure, and an arthrotomy procedure is always performed as a component service. Code 28024 is considered a component service and will not be reimbursed when reported on the same claim as code 28285.
It is important to note that the appropriate use of modifiers can mitigate some NCCI edits. CPT Modifiers 58, 59, 78, 79 and 91 may be used along with HCPCS Level II modifiers E1-E4, FA, F1-F9, LC, LD, LT, RT, TA and T1-T9. Documentation in the medical record must support the use of these modifiers.
Outpatient Code Editor (OCE)
CMS has embedded in the OCE all functions that require specific reference to CPT and HCPCS procedure codes and ICD-9-CM diagnosis codes. The OCE includes code validity edits, as well as edits for:
• Diagnosis/Procedure and Age or Sex Conflicts;
• Appropriate Use of Modifiers; and
• CCI edits.
There are some differences between the CCI edits used in the OCE and the NCCI used for professional billing. One major difference is that the CCI edit table used in the OCE is one quarter behind the NCCI edit table. In some instances, the code pairs may be different or CCI edits may not trigger because other OCE edits apply to the case.
The OCE contains four edits that utilize the NCCI edit tables:
Edit #19: Mutually exclusive procedure that is not allowed even if appropriate modifier is present
• 11719 Trimming of nondystrophic nails
• 11721 Debridement of nails any method; 6 or more
Edit #39: Mutually exclusive procedure that would be allowed if appropriate modifier is present
• 11200 Removal Multiple Skin Tags 1-15
• 11400 Excision Benign Skin Lesion <.5 cm
Edit #20: Component of a comprehensive procedure that is not allowed even if appropriate modifier is present
• 12001 Simple Repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk or extremities; 2.5 cm or less
• 12002 Simple Repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk or extremities; 2.6 cm to 7.5 cm
Edit #40: Component of a comprehensive procedure that would be allowed if appropriate modifier is present
• 28290 Simple Hallux Valgus Correction
• 28288 Partial Metatarsectomy, Single
It is important to understand the distinction between the CCE edits included in the OCE and the NCCI edits used to edit professional claims. For additional information, go to the CMS Web site at: http://www.cms.hhs.gov/NationalCorrectCodInitEd. After reviewing this information take the following quiz.
1. All providers of care can use the same set of NCCI edits?
2. A patient presents to the doctor's office for an EKG. Later in the day a stress test is performed at a cardiac outpatient facility. Are these services subject to NCCI edits?
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, facility solutions, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix.
CPT is a registered trademark of the American Medical Association.
1. b. All providers should not use the same set of NCCI edits. There are two sets of NCCI edits, one set is utilized for hospital reporting and the other set for physician reporting.
2. b. In this instance, the EKG and stress test are not subject to NCCI edits. NCCI edits apply to services performed by the same provider on the same date of service to the same patient. In this instance, even though the services are preformed on the same day, they were not performed by the same provider.