Notification



Notification Issue Date:



Medicare Advantage Policy

Title:National Correct Coding Initiative (NCCI) Code Pair Edits
Policy #:MA00.041

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

If procedure codes identified within the National Correct Coding Initiative (NCCI) edit pair file are reported for the same individual on the same date of service, by the same provider, the Company will apply the associated NCCI edit for those code pairs.

Modifiers may be appended to these procedure code pairs when appropriate based on the Centers for Medicare and Medicaid Services (CMS) NCCI modifier indicators for each code pair edit.

Procedure code pairs designated by CMS with an NCCI modifier indicator of 0 (zero) are not eligible to be reimbursed separately when reported on the same date of service for the same member when performed by the same provider. The NCCI edit identified in the CMS NCCI file for these procedure code pairs will be applied by the Company regardless of the presence of a modifier.

Procedure code pairs designated by CMS with an NCCI modifier indicator of 1, when clinically appropriate, are eligible to be reported with an appropriate modifier for separate reimbursement.

Refer to the CMS NCCI file for procedure code pair edits and the associated modifier indicators.
Policy Guidelines

Modifiers may be appended to procedure codes if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a procedure code solely to bypass an NCCI edit if the clinical circumstances do not justify its use.

This policy does not contain an all-inclusive list of procedure code editing applied by the Company. Procedure codes continue to be subject to Company claims adjudication logic, eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies.

Description

CMS NCCI (also known as CCI) is a tool that was developed by CMS to promote national correct coding methodologies to ensure appropriate payment.

The CMS CCI tables (Column 1/Column 2) are composed of code pair edits. These code pair edits identify services that are a component of a more comprehensive code or two codes that should not be reported together.

CMS assigns modifier indicators to each procedure code pair to identify when it may be appropriate to append a modifier to indicate that separate payment may be warranted. Modifier indicator 0 (zero) is assigned to procedure code pairs when there are no modifiers associated with NCCI edits that are allowed to be used with that given procedure code pair. For these procedure code pairs, there are no circumstances in which both procedures of the code pair should be reimbursed for the same member on the same day when performed by the same provider. Reporting a modifier does not override the NCCI edit for these procedure code pairs. Modifier indicator 1 is assigned to procedure code pairs to indicate that modifiers associated with NCCI are allowed with the code pair when appropriate. Modifier Indicator 9 is assigned to procedure code pairs when an NCCI edit does not apply to that code pair because the edit was deleted retroactively.

CMS updates the NCCI files quarterly.
References

Centers for Medicare & Medicaid Services (CMS). How to Use the Medicare National Correct Coding Initiative (NCCI) Tools. MLN Booklet. [CMS Web site]. ICN 901346 January 2019. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/How-To-Use-NCCI-Tools.pdf. Accessed June 19, 2019.

Centers for Medicare & Medicaid Services. National Correct Coding Initiative Edits. [CMS Web site]. 5/28/19. Available at: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd. Accessed June 19, 2019.

Centers for Medicare & Medicaid Services (CMS). PTP Coding Edits. [CMS Web site]. 5/28/19. Available at:
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html. Accessed June 19, 2019.

Novitas Solutions. National Correct Coding Initiative (NCCI) Edits Apply to OPPS and Non-OPPS Claims. [www.novitas-solutions.com]. 1/4/19. Available at:
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00184101. Accessed June 19, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to the CMS NCCI file for procedure code pairs edits and associated modifier indicators


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

Refer to the CMS NCCI file for procedure code pairs edits and associated modifier indicators


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA00.041:
08/14/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on National Correct Coding Initiative (NCCI) Code Pair Edits.
01/01/2015This is a new policy.






Version Effective Date: 01/01/2015
Version Issued Date: 01/01/2015
Version Reissued Date: 08/14/2019