CMS releases third and fourth quarter NCCI edits
Derm Coding Consult
By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Manager, Coding & Reimbursement, January 1, 2022
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CMS has released its third and fourth quarterly updates to the National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits. Version 27.2 and version 27.3 went into effect on July 1, and Oct. 1, 2021, respectively.
NCCI PTP edits overview
The NCCI PTP code pair edits were designed to prevent improper payments when incorrect code combinations are reported for Medicare Part B covered services by physicians and non-physician clinicians (NPCs).
The NCCI table lists Healthcare Common Procedure Coding System code and Current Procedural Terminology (HCPCS/CPT) code combinations that are mutually exclusive from one another. When these codes are billed together on the same day by the same physician or NPC for the same patient, one of the services may be bundled into the primary procedure resulting in denial of the claim line. To avoid bundling of claim lines, one of the codes must be appended with a modifier to indicate that the service was performed either:
during a different session,
during a different procedure or surgery,
on a different site or organ system,
as part of a separate incision/excision,
OR
on a separate lesion.
Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. However, if it is clinically appropriate to use an NCCI PTP-associated modifier, both the column one and column two codes are eligible for payment.
Although there are currently not many changes to dermatology-related NCCI edits, it is important for dermatology practices to conduct periodic reviews of the NCCI table to ensure that where applicable, the claim line is appended with the appropriate modifier(s).
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Medically Unlikely Edits (MUEs)
In its continued effort to lower the Medicare Fee-For-Service (MFFS) paid claims error rate, CMS has also established units of service edits known as Medically Unlikely Edits (MUEs). An MUE for a HCPCS/CPT code is the maximum unit of service that a dermatologist or NPC would report under most circumstances for a single beneficiary on a single date of service.
Not all HCPCS/CPT codes have an MUE; however, Medicare Administrative Contractors (MACs) test codes with established MUEs against these edits during claim adjudication. Codes reported with MUEs more than the established maximum units are denied.
MUE values for each HCPCS/CPT code are based on and described by an MUE Adjudication Indicator (MAI). Every dermatology practice must conduct a periodic review of the NCCI PTP and MUE indicators to understand the rationale for MUE claim denial(s) so that claim appeals based on NCCI or MUE edits can be successfully addressed.
Reporting a service/procedure in excess of MUEs
Certain billing circumstances may clinically require reporting the service in excess of the listed MUE. For example, CPT code 88342 - Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure has an MUE of 4 and an MAI of 3 – date of service - clinical edit. When more than four units of this service are performed by the same provider on the same date of service to the same patient, the excess units can be appealed with medical records to justify the medical necessity.
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Appealing claims denied due to excess MUEs
Claim denials based on MUE MAI are sometimes appealable — depending on the MUE rationale. Below are the MUE indicators and their interpretation as well as actions you can take to appeal denied claims once they meet appeal criteria.
| MUE Adjudication Indicator | MUE rationale | Action | Example |
|---|---|---|---|
1 Claim line |
Clinical: Data |
Maximum MUE units must be adhered to on the date of service (DOS). |
CPT code 0480T - Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2. If additional units in excess of the MUE limit must be reported, appropriate CPT modifiers (e.g., 59 or -X{EPSU}, 76, 77, 91, anatomic) may be used to report the same HCPCS/CPT code on separate lines of a claim. Each line of the claim will be separately adjudicated against the MUE value for that HCPCS/CPT code. |
2 Date of service edit: Policy |
Code descriptor/ CPT |
Absolute date of service edit. The claim is not appealable because limitations are created by anatomical or coding guidelines. Codes with MAI “2” have been rigorously reviewed and vetted within CMS and are assigned this designation because UOS on the same DOS in excess of the MUE value would be considered impossible because it was contrary to statute, regulation, or sub-regulatory guidance. This sub-regulatory guidance includes a clear correct coding policy that is binding on both providers and CMS claims processing contractors. Limitations created by anatomical or coding limitations are incorporated in the correct coding policy, both in the HIPAA-mandated coding descriptors and CMS-approved coding guidance as well as specific guidance in CMS and NCCI manuals. |
CPT code 96573 – Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day. |
3 Date of service edit: Clinical |
Clinical: Data |
“Per day” edit based on clinical benchmarks. Maximum units of service per day must be adhered to. If claim denials based on these edits are appealed, MACs may pay UOS in excess of the MUE value if there is adequate documentation of the medical necessity of correctly reported units. |
CPT code 17311 - Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks when reported with more than 4 units on the same date of service can be appealed with medical records. |
View the Quarterly Update to the NCCI PTP Version 27.2 and 27.3. See information on MUE Adjudication Indicators.
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