What is NCCI?
The National Correct Coding Initiative is CMS's set of coding edits that stops pairs of procedures from being paid together when one is part of the other, and limits units per service.
NCCI procedure-to-procedure edit
| Column 1 | Column 2 | Modifier indicator | Meaning |
|---|---|---|---|
| 29881 Knee arthroscopy, meniscectomy | 29877 Knee arthroscopy, debridement | 1 | Not paid together, unless a modifier shows separate sites |
| 36415 Venipuncture | 36592 Blood draw from catheter | 0 | Never paid together, no modifier allowed |
- Indicator 1 allows a modifier like 59 or XS when the record documents a distinct service. Indicator 0 doesn't, whatever the documentation.
CMS created NCCI to stop improper payment for services that shouldn’t be billed together. Medicare and Medicaid apply it, and most commercial payers use it or something like it.
Two kinds of edits
- Procedure-to-procedure (PTP) edits: pairs of codes billed by the same provider for the same patient on the same day. The column-two code is denied, unless the pair allows a modifier and the services were distinct. Denials come back as CO-97 or CO-236.
- Medically Unlikely Edits (MUEs): the most units of a service a provider would report for one patient on one day.
Modifiers that bypass a pair
59 and the more specific XE (separate encounter), XS (separate structure), XP (separate practitioner) and XU (unusual non-overlapping service) say the services were distinct. They’re only valid when the record shows it, and they’re among the most audited modifiers in billing.
Updates
The edits are updated every quarter, so a scrubber’s tables have to be too.
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