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How to Use The National Correct Coding Initiative (NCCI) Tools - PowerPoint PPT Presentation

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How to Use The National Correct Coding Initiative (NCCI) Tools. Presented by Lori Dafoe, CPC. Agenda . How it Impacts You NCCI History and Definition Using the NCCI Tools/AAPC Coder Real Life Examples Resources. Why Use It?.

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Presentation Transcript
  • How it Impacts You
  • NCCI History and Definition
  • Using the NCCI Tools/AAPC Coder
  • Real Life Examples
  • Resources
why use it
Why Use It?
  • Accurate coding and reporting is a critical aspect of proper billing.
  • Helps providers avoid coding and billing errors and subsequent payment denials.
  • Service denied on NCCI code pair edits or MUEs may not be billed to Medicare beneficiaries.
  • Provider cannot utilize an ABN to seek payment from a Medicare beneficiary.
background and history
Background and History
  • NCCI was originally developed for Medicare in 1996
  • Founded on Coding Policies
ncci website
NCCI Website
what are code pair edits
What are “code pair edits”?
  • NCCI code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.

Column I and Column II

  • Column I and Column II Procedures should be reported with the most comprehensive CPT code that describes the services performed.
  • Physicians must not unbundle or report multiple Healthcare Common Procedure Coding System (HCPCS)/CPT codes when a single comprehensive code describes the services that were furnished.
mutually exclusive edits
Mutually Exclusive Edits
  • Procedure codes that cannot be reported together because they are mutually exclusive of each other.
  • Mutually exclusive procedures cannot reasonable be performed at the same anatomic site or same patient encounter.
  • Two or more procedures performed during the same patient encounter on the same date of service and the same billing provider that are not normally performed together.
medically unlikely edits mues
Medically Unlikely Edits (MUEs)
  • HCPCS/CPT’s have a defined unit of service for reporting purposes.
  • Providers that bill units of service for a HCPCS/CPT code using a criteria that differs from the code’s defined unit of service will experience a denial.
  • MUE editing is based on the edits of service allowed on the claim, not the units of service billed.
use of modifiers
Use of Modifiers
  • Modifiers may be appended to HCPCS/CPT codes only when clinical circumstances justify the use of the modifier.
  • A modifier should not be appended to a HCPCS/CPT code solely to bypass NCCI editing.
  • The use of modifiers affects the accuracy of:
    • Claims billing
    • Reimbursement
    • NCCI editing
    • Clarification of procedures
modifiers allowed with cci
Modifiers Allowed with CCI
  • The following anatomical modifiers are allowed:

E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9

  • The following global surgery modifiers are allowed:

25, 58, 78, 79

  • Other modifiers allowed:

59, 91

ncci edits and how they work
NCCI Edits and How they Work
  • Type I

NCCI Code Pair Edits

(Procedure – to -Procedure)

  • Type II

Medically Unlikely Edits (MUEs)

mutually exclusive procedures
Mutually Exclusive Procedures

Policy: Modifier -59 is allowed if appropriate documentation is present.

cpt coding manual instruction guideline
CPT Coding Manual Instruction/Guideline

Policy: Modifier -59 is allowed if appropriate documentation is present.

more extensive procedure
More Extensive Procedure

Policy: Modifier -59 is allowed if appropriate documentation is present.

how to locate ncci tables and manual
How to Locate NCCI Tables and Manual
  • Code pair edits, MUE tables, and NCCI manual are accessed on the CMS website at

  • How to Use the NCCI Tools
  • NCCI Policy Manual for Medicare Services
  • Modifier -59 Article: Proper Usage
modifier 59 cpt manual definition
Modifier -59, CPT Manual Definition
  • Different session
  • Different patient encounter
  • Different procedure or surgery,
  • Different site or organ system,
  • Separate incision/excision,
  • Separate lesion, or
  • Separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.
example appeal modifier 59
Example Appeal, Modifier 59

To Whom It May Concern.:

The following information is being provided to clarify our use of the CPT modifier 59 reported with [procedure name] CPT [code] to indicate that the services are not typically performed together and warrant separate reimbursement.

The CPT modifier 59 was developed by the American Medical Association explicitly for the purpose of identifying services not typically performed together. According to CPT codes, guidelines and conventions, CPT modifier 59 is appended to indicate that under certain circumstances the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. According to the CPT Book, “Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under these circumstances.” [reason procedure or service was performed.]

The appropriateness of appending modifier 59 on CPT [procedure code] is clearly documented within the patient’s chart and should be recognized by [health plan].

Based on the circumstances of this case, we are requesting that CPT code [code] be considered for separate reimbursement and not bundled under payment for the procedure. Please forward this information to your medical review staff for an independent determination to prevent a computer generated denial based on coding edit software that commonly occurs with CPT modifier 59 claims.

Thank you for your consideration. Please contact [contact name] at [telephone number] in our office should you have any questions regarding this claim.



coding scenario 1
Coding Scenario 1:
  • Yes!
  • -59
  • Append to CPT 11100 (Column II Code).
  • Rationale: Excision of malignant lesion of face was a separate site from the two biopsies that were performed (left ear/helix, and right side of neck.
coding scenario 2
Coding Scenario 2:
  • Yes!
  • -59
  • Append to CPT 26115 & 26111 (Column II Codes).
  • Rationale: Excision of tumors were performed on separate digits, requiring separate incisions and repairs.
coding scenario 3
Coding Scenario 3:
  • No!
  • N/A
  • N/A
  • Rationale: Even though this was a separate encounter on the same date, NCCI edits do not allow for these codes to be billed together under any circumstances.
coding scenario 4
Coding Scenario 4:
  • No!
  • N/A
  • N/A
  • Rationale: The comprehensive metabolic panel includes a total calcium.
coding scenario 5
Coding Scenario 5:
  • Yes!
  • -59
  • Append to CPT 11301 (Column II Code).
  • Rationale: Separate lesions. Shave excision performed foor lesion on patient’s back, while AK’s were destroyed from the patient’s face.
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