Is There an NCCI Edit for Those Codes?

Is There an NCCI Edit for Those Codes?

Is There an NCCI Edit for Those Codes?

Know how to find the answer and improve your clean claims rate.

Medicare revises its National Correct Coding Initiative (NCCI) edits on a quarterly basis. As a medical coder, not only must you keep up with these updates to ensure correct coding, but you need to know how to read the edit files. Here are a few tips that will help you stay on top of practitioner procedure-to-procedure (PTP) edits and avoid the dreaded 97 error message.

What is NCCI?

The Centers for Medicare & Medicaid Services (CMS) established NCCI to prevent providers from reporting (and getting paid for) certain services that shouldn’t be billed together on the same day by the same practitioner. For instance, the code for a larger procedure may include payment for a lesser service also captured in a separate code. Reporting both codes is “double-dipping.” NCCI edits flag claims that would create this sort of overpayment.

Each PTP edit has a column 1 code and a column 2 code, as well as a modifier indicator. The codes can be CPT® or HCPCS Level II codes.

  • If the modifier indicator is “0,” reporting the edit pair for the same Medicare patient and provider on the same date of service will result in denial of the column 2 code.
  • If the modifier indicator is “1,” you may (if appropriate) append one or more NCCI PTP-associated modifiers, so both codes are eligible for payment.

Denied claims are returned with error message 97 The benefit for this service is inclined in the payment or allowance for another service or procedure that has already been adjudicated. Medicare Administrative Contractor Novitas recently posted its May 2020 top claim submission errors and this error made the top six in its jurisdictions (JL and JH).

Medicare typically updates NCCI edits quarterly, with new versions effective Jan. 1, April 1, July 1, and Oct. 1. In rare cases, Medicare issues replacement files during the quarter. This year, in the second quarter update, Medicare deleted more than 290,000 edit pairs to PTP edits for practitioner services in response to the COVID-19 public health emergency, according to Medicare’s NCCI Edits page.

Medicare has an NCCI PTP Coding Edits page with links to recent PTP edit files. At the time of this writing, there are links to files for hospital and practitioner edits effective April 1, 2020 and July 1, 2020.

Tip 1: Check All Columns in Medicare’s PTP Coding Edits File

To determine whether certain CPT® or HCPCS Level II codes are part of an edit pair for professional claims (e.g., place of service 11), download the files that include “practitioner” in the name. Because there are so many edits, there are multiple links with code ranges listed at the end of the link name, such as “Practitioner PTP Edits v261r1 effective April 1, 2020 (532,940 records) 0001M/36591 – 25999/96523.” The range listed at the end of the name lets you know that the file includes edits with column 1 codes from 0001M to 25999.

Let’s say you want to check whether there is a Medicare NCCI PTP edit for CPT® codes 11102 Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion and 99213 Office or other outpatient visit for the evaluation and management of an established patient … for a May 2020 date of service.

Click on the link named above because 11102 is between 0001M and 25999. You will likely have to click a button to accept Medicare’s terms before you can download a zip file. In the folder, you have an Excel file and text files. For this example, we’ll use the Excel file.

At the top of the spreadsheet, you’ll see columns with the labels shown below:

Column 1Column 2             *=in existence prior to 1996Effective DateDeletion Date     *=no data  Modifier 0=not allowed 1=allowed 9=not applicable  PTP Edit Rationale             

Scroll down the spreadsheet or use the (much faster) Find function to locate 11102 in the first column. Tip: Limit your search to column A to speed up the process even more.

Once you reach the section with 11102 column 1 codes, find the row with 99213 as the column 2 code.

Here’s how the data appeared on May 27, 2020:

Column 1Column 2           *=in existence prior to 1996Effective DateDeletion Date     *=no data  Modifier 0=not allowed 1=allowed 9=not applicable  PTP Edit Rationale             
111029921320190101201912311CPT® Manual or CMS manual coding instructions

The strings of numbers in the Effective Date and Deletion Date columns provide dates in year/month/day format. In this example, the effective date is 2019/01/01 (Jan. 1, 2019) and the deletion date is 2019/12/31 (Dec. 31, 2019).

The file shows that for the May 2020 date of service, there is no active practitioner NCCI PTP edit for 11102/99213. The spreadsheet lists Dec. 31, 2019, as the deletion date for the edit. If the Deletion Date column had an asterisk (*) instead of a date, then this edit is still valid.

The lesson here is that you should always check the effective and deletion date columns in the most recent NCCI files when confirming whether an NCCI edit is valid for the date of service.

To be sure there is no edit for the two codes, also check the reverse, with 99213 in column 1 and 11102 in column 2. In this case, the NCCI file that lists edits with 99213 in column 1 shows no edit for 99213/11102.

When the edit was valid (between the effective and deletion dates), the modifier indicator for our sample edit was “1,” as shown in the Modifier column. That means that you were able to override the edit with a modifier when documentation and clinical circumstances supported doing so. As explained earlier, a “0” means you may never bypass the edit, even with a modifier. Edits deleted retroactively, as if they never existed, have a “9” in this column.

The final column, PTP Edit Rationale, shows that the edit was originally created because either CPT® or CMS coding instructions limited the ability to report the codes together. To see what sort of response you can expect from payers, check out the Correspondence Language Manual for Medicare Services available on the NCCI Edits page.

Tip 2: Use NCCI Quarterly Update Site With Care

Medicare’s “Quarterly PTP and MUE Version Update Changes” site is a great place to check when you want to scan what’s new in a quarter for NCCI PTP edits and Medically Unlikely Edits (MUEs).

Select the correct link for your date and edit type (such as the July 1, 2020, quarterly replacement file for practitioner PTP NCCI edits). You can look through lists that separately identify edit additions, deletions, and modifier indicator changes. But there are a few things to keep in mind when using these handy lists.

First, the quarterly update lists show the column 1 code, the column 2 code, and the modifier indicator. There are no columns for the effective and deletion dates or the edit rationale, so the quarterly update lists don’t provide as much information about an edit as the complete files do.

Also, the quarterly update sheets don’t have a separate list for when codes swap columns in an edit. Before you celebrate an edit deletion, check the list of additions to see if Medicare still has an edit for the codes, and only switched which code is in column 1 and which is in column 2.

Finally, if there’s a conflict between the quarterly update file and the complete listing, you can bet payers will follow the complete file. (To be fair, in this time of rapid changes, the quarterly update site announced the second quarter replacements before the main files were updated. But, as a general rule for less chaotic times, it’s probably safer to consider the complete file to be more authoritative.)

Tip 3: Remember Additional Rules and Resources

Before finalizing your claim, make certain you’re applying coding edits correctly.

For instance, an edit deletion or a change to “1” for a modifier indicator isn’t a green light to report two codes together. You still need to consider whether it’s appropriate to report the two codes together for a particular encounter. You may find helpful hints in the Medicare NCCI Manual, which explains the rationale for many edits and when it’s OK to override them using modifiers.

The NCCI Edits page also has an important note specific to the second quarter 2020 deletions: “Although NCCI files have dates consistent with the first day of each quarter and are therefore dated retroactively to January 1, 2020, payments based on the expansion of telehealth services are for dates of services starting March 6, 2020.”

Make sure you’re applying the correct set of edits, too. Medicare provides separate edits for practitioners and for outpatient hospitals on the NCCI PTP Coding Edits page. Medicaid has its own NCCI edits. And private payers can create edits that apply only to their claims.

There’s a lot to remember when it comes to code edits, but knowing and applying NCCI edits correctly will pay off. Fewer coding errors means faster claims processing and less rework to bring in reimbursement.

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