CMS releases 2023 third and fourth quarter NCCI edits
Derm Coding Consult
By Tiffany E. McFarland, RHIT, Analyst, Coding & Reimbursement, January 1, 2024
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CMS has released the third and fourth quarter updates to the National Correct Coding Initiative Procedure-to-Procedure edits (NCCI PTP) and published them to the Medicare-Medicaid coordination website under the Fraud, Waste, and Abuse (FWA) Prevention section. Version 29.2 and version 29.3 went into effect on July 1, 2023, and Oct. 1, 2023, respectively.
Overview of CMS NCCI edits
CMS designed the NCCI PTP code pair edits to proactively address potential issues related to incorrect payments arising when mutually exclusive procedures are reported together. To achieve this, CMS uses an Excel table where each row represents a distinct PTP edit pair. Column One and Column Two of this table contain CPT codes, along with a correct coding modifier indicator (CCMI). PTP edits are essentially pairs of HCPCS/CPT codes that, under normal circumstances, should not be billed together. In cases where both codes from Column One and Column Two are reported on the same service date, only the code from Column One is eligible for reimbursement unless a clinically appropriate NCCI PTP-associated modifier is applied.
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Correct Coding Modifier Indicators
The CCMI serves as a crucial indicator to determine whether an NCCI-associated modifier can facilitate the bypassing of edits and, thereby, allow reimbursement for both codes. A CCMI of “0” signifies that the particular code pair cannot bypass the edits with the aid of a modifier, while a CCMI of “1” indicates an edit that warrants a modifier to bypass. CCMI of “9” means the use of NCCI-associated modifiers is not specified and/or that the effective date of the NCCI instruction is the same as the date it was deleted.
The following table includes examples of some dermatology code combinations reflecting CCMI indicators:
| Column 1 | Column 2 | Effective date | Deletion date * = no data | Modifier 0 = not allowed 1 = allowed 9 = not | PTP edit rationale |
|---|---|---|---|---|---|
99213 |
99358 |
20210101 |
* |
0 |
CPT Manual or CMS manual coding instructions |
69100 |
11102 |
20190101 |
* |
1 |
Mutually exclusive procedures |
11201 |
10060 |
19960101 |
19960101 |
9 |
Standards of medical/surgical practice |
Medically Unlikely Edits
Parallel to the NCCI edits, Medically Unlikely Edits (MUEs) are also subject to regular updates, which are released quarterly. MUEs are designed to curb excessive or inappropriate billing for medical services. An MUE for a HCPCS/CPT code is the maximum number of units a dermatologist or non-physician clinician can report for a beneficiary on a single date of service.
MUE values for each HCPCS/CPT code are based on and described by an MUE Adjudication Indicator (MAI). An MAI of “1” denotes a claim line edit, which means that each reported service is adjudicated as a claim line edit.
If a claim is denied based on MAI 1, the edit can be corrected by reporting services that are in excess of the MUE limit on a separate claim line. For example, HCPCS code A6460 has an MAI 1. However, if more than one unit has been used, report the additional unit on a separate claim line of the CMS 1500.
An MAI of “2” is an absolute date of service policy edit. Exceeding the maximum units of service (UOS) on a date of service will result in claim denial. An example of this is CPT code 11102 - Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); single lesion, is reported once per date of service as indicated by the CPT code descriptor.
An MAI of “3” indicates a clinical date of service edit. These “per day edits” are based on clinical benchmarks rooted in medical necessity considerations. For example, in addition to the first tangential biopsy (CPT code 11102), MUE guidelines allow for one to report six additional tangential biopsies (CPT 11103) to the same patient on the same date of service.
Below is an illustration of the MAI indicators:
| MUE unit | MUE Adjudication Indicator | MUE rationale | Action | Example |
|---|---|---|---|---|
1 |
1 - Claim line edit |
Clinical: CMS |
Maximum MUE units must be adhered to on the date of service (DOS). |
HCPCS code A6460 – Synthetic resorbable wound dressing, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
1 |
2 - Date of service edit: Policy |
Date of service edit: Policy |
Absolute date of service edit. |
CPT code 11102 – Tangential biopsy of skin |
3 |
3 - Date of service edit: Clinical |
Date of service edit: |
“Per day” edit based on clinical benchmarks. |
CPT code 11103 – Tangential biopsy of skin |
Revenue cycle management
It is incumbent upon dermatology practices to diligently review the NCCI PTP edits and MUE updates as an integral component of their revenue cycle management activities. Such proactive measures serve to mitigate financial risks, including denied claims, reporting anomalies, and the associated costs with the appeals process for denied claims.
Visit the Coding Resource Center at staging.aad.org/coding for more guidance and additional coding resources.
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