CMS releases 2023 first and second quarter NCCI Edits
Derm Coding Consult
By Tiffany E. McFarland, RHIT, Analyst, Coding & Reimbursement, July 1, 2023
Academy coding staff address important coding topics each month in DermWorld Coding Consult. Read more Derm Coding Consult articles.
CMS has released the first and second quarter updates to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure Edits and moved them to the Medicare-Medicaid coordination website, under the Fraud, Waste and Abuse (FWA) Prevention section. The NCCI Edits are accessible at cms.gov. Version 29.0 and version 29.1 went into effect on Jan. 1, 2023, and April 1, 2023, respectively.
There are no dermatology-specific changes in these edit files.
Academy coding resources
Check out the Academy’s coding resources.
CMS National Correct Coding
Initiative Edits overview
CMS develops coding policies based on the American Medical Association (AMA), Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) coding conventions, national and local coverage determinations (NCD/LCD), national societies’ coding guidelines, and the standard medical and surgical practices.
The NCCI PTP code pair edits aim to prevent improper payment when one reports mutually exclusive procedures together. CMS houses the code pair edits within an Excel Column One and Column Two formatted table. When these code combinations are reported on the same service date, the Column One code is eligible for reimbursement but not the Column Two code, unless a clinically appropriate NCCI PTP-associated modifier is also reported. The table employs an indicator known as the Correct Coding Modifier Indicator (CCMI) to signify the outcome of the reported code combination.
Correct Coding Modifier Indicators (CCMI)
The indicator determines whether an NCCI-associated modifier (see list below) will permit the code pair to bypass edits and reimburse both codes.
A modifier indicator of “0” means no NCCI-associated modifier will bypass the edit(s), “1” indicates an NCCI-associated modifier will bypass the edit(s), and “9” means that the code combination has been deleted and no NCCI-associated modifier is required.
CCMI | CCMI descriptor | Code combination example Column 1 | Code combination example Column 2 | Rationale | Resolve |
|---|---|---|---|---|---|
0 | An NCCI-associated modifier is not allowed and will not bypass the edit | 11106 | 11104 | CPT Manual or CMS manual coding instructions | Codes with this CMMI cannot be paid for the same patient on the same DOS by the same provider. Only one primary skin biopsy code can be reported on the same DOS. The incisional biopsy is reported as primary code; report an add-on code for the punch biopsy (e.g., 11105) |
1 | An NCCI-associated modifier is allowed and will bypass the edit | 11102 | 17260 | Mutually exclusive procedures | Edit can be bypassed and the column two code may be eligible for payment if an NCCI-associated modifier is appropriately appended to one of the codes |
9 | The use of NCCI-associated modifiers is not specified. This indicator is used for all code pairs that have a deletion date that is the same as the effective date | 11201 | 11300 | Mutually exclusive procedure | This indicator was created so that no blank spaces would be in the indicator field. Edit expired 6/1/1996 |
NCCI-associated modifiers that are allowed to bypass an NCCI PTP code pair edit:
Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
Global surgery modifiers: 24, 25, 57, 58, 78, 79
Other modifiers: 59, 91, XE, XS, XP, XU
Medicare NCCI Policy Manual
The best reference tool for accurately billing Medicare approved services is the NCCI Policy Manual. CMS developed and continuously revises the NCCI edits manual quarterly to better define various Medicare billing requirements and service restrictions, including detailed explanations of the Medical and Surgical package, Evaluation and Management (E/M) services, and Medically Unlikely Edits (MUEs). Most private payers follow and implement these guidelines into their claim adjudication policies.
Section I. CPT Manual and CMS Coding Manual Instructions of Chapter I - General Correct Coding Policies is an example of the vital information within the NCCI Policy Manual. CMS instructs physicians and non-physician clinicians (NPC) to follow CMS when the CPT Manual coding instructions conflict for services billed to Medicare beneficiaries.
Medically Unlikely Edits (MUEs)
CMS created the NCCI Medically Unlikely Edits (MUEs) to reduce improper payments for Part B claims. MUEs specify, by HCPCS/CPT code, the maximum units of service that a dermatologist or NPC may report under most circumstances for a Medicare beneficiary per day. Not all HCPCS/CPT codes have MUE limits.
CMS updates MUEs quarterly. The 2023 Quarter 1 revised edit file is available at cms.gov.
Note: According to CMS, please use the 2023 Q1 Edit Files until CMS posts the 2023 Q3 Edit Files.
Derm Coding Consult
Get more expert coding advice from Derm Coding Consult.
More coding guidance and resources can be viewed on the AADA Coding Resource center at staging.aad.org/coding.
Additional DermWorld Resources
In this issue
The American Academy of Dermatology is a non-profit professional organization and does not endorse companies or products. Advertising helps support our mission.
Opportunities
