MA PPO

National Correct Coding Initiative (NCCI) Code Pair Edits
MA00.041


Policy

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.

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

CPT Procedure Code Number(s)

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

ICD - 10 Procedure Code Number(s)
N/A

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

1/1/2015
1/1/2015
8/14/2019
MA00.041
Claim Payment Policy Bulletin
Medicare Advantage
Yes