Correct Coding Initiative: A system of coding edits developed by CMS in conjunction with AdminaStar Federal, Inc. to be utilized nationally by all Medicare carriers. The code edits were developed based on review of CPT™ code descriptors, CPT coding instructions and guidelines, local Medicare carrier national edits, and Medicare billing history.
The correct coding edits that resulted from this process have now been incorporated into claims processing systems used by Medicare carriers to determine payments to physicians.
Incidental Procedure: Procedures that can be performed along with the primary procedure, but are not essential to complete that procedure. Often these codes are identified by CPT nomenclature as “separate procedures.”
Mutually Exclusive Procedure: Mutually exclusive procedures are a coding combination billed in error that follows one or both of the following criteria: Either the two services cannot reasonably be done in the same session, or the coding combination represents two methods of performing the same service.
Rebundling/Bundling: Reimbursement denial for any additional billed services that are components of or inclusive to, or mutually exclusive of a more comprehensive procedure performed in the same session by the same provider.
Unbundling: To inappropriately bill more CPT/HCPCS codes than necessary. Applied when certain codes represent procedures that are basic steps to accomplish a primary procedure already on the bill and, by definition, are included in the reimbursement of the primary procedure.
POLICY
The AMA Current Procedural Terminology (CPT) codebook is a systematic listing of procedures and services performed by physicians. It is a compendium of descriptions that depicts the various medical services available, identified by a five-digit code. The use of the CPT codes allows the physician to accurately identify the services rendered and report for reimbursement. All aspects of medicine or surgical services are subject to certain parameters as part of the reimbursement process.
The process of assigning a CPT code to a procedure or service is dependent on both the procedure performed and the documentation that supports it. When multiple procedures are performed in the same session, only one procedure may be listed as the primary procedure and any additional codes may be considered inherently part of the primary procedure or other billed procedures or mutually exclusive to the procedures. All CPT codes billed are subject to review for rebundling.
PROCEDURES AND RESPONSIBILITIES
When two or more related procedures are performed on a patient during a single session or visit, Oxford will reimburse the provider for the comprehensive code and deny or adjust the component, incidental or mutually exclusive procedure performed during the same session. The rebundling guidelines in this policy are based on The Correct Coding Initiative administered through the Centers for Medicare & Medicaid Services (CMS), AMA Current Procedural Terminology (CPT Code) and additional general industry accepted guidelines.
To rebundle a claim, Oxford claims system utilizes a software package assembled by IntelliClaim (owned by McKesson Health Solutions). IntelliClaim’s product provides a platform on which two off-the-shelf and widely used products (referenced below) are combined with a flexible environment that allows Oxford to develop, customize & update our payment guidelines as necessary. Through their product, the efficiency, accuracy and speed with which millions of edits can be applied, the detailed documentation supporting the logic behind the rules, and the clear explanations for claim adjustments result in more automated claim processing, faster turnaround, more consistent and understandable results, and improved customer service. As part of the IntelliClaim package, IntelliClaim has incorporated two software packages to rebundle codes. These software packages are the Correct Coding Initiative Software by The National Technical Information Service (NTIS) and effective October 6, 2006, ClaimsXten™ by McKesson.
The NTIS software provides Oxford with the Correct Coding Rules used by CMS. This software is the same software product used by fiscal intermediaries that process Medicare Fee for Service claims for CMS. The Correct Coding Rules can be found on CMS’s website at www.cms.gov. The IntelliClaim software incorporates the quarterly updates that CMS makes to the Correct Coding rules into Oxford’s claims processing system. ClaimsXten™ contains KnowledgePacks consisting of rules that, among other things, characterizes coding relationships on provider medical bills. ClaimsXten provides information that allows claims submitters, claims processors and adjudicators to identify potentially incorrect or inappropriate coding relationships by a single provider, for a single patient, on a single date of service. Examples of the rules include incidental, mutually exclusive, unbundling and visit edits. Sources of the KnowledgePacks include the AMA and CPT publications, CMS, specialty societies and McKesson physician consultants. Please note this Reimbursement policy is subject to Oxford’s reimbursement policies and rules. Refer to the Modifier Reference Policy for additional information
For the first quarter of 2015, additional hospital and physician NCCI edit files have been provided which contain an edit rationale column. These files, labeled as “NTIS format” are formatted to match the files previously supplied by NTIS. For the January, 2015 release the structure of the current NCCI edit data files will remain unchanged and both versions will be posted. However, these two files structures will be consolidated into a single format for future releases.
Important notice to all NCCI Users concerning the National Correct Coding Initiative Policy Manual for Medicare Services:
The annual updated version of the National Correct Coding Initiative Policy Manual for Medicare Services will be effective January 1, 2015. Additions/revisions to the manual have been italicized in red font.
National Correct Coding Initiative
The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association’s CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. The CMS annually updates the National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual should be utilized by carriers and FIs as a general reference tool that explains the rationale for NCCI edits.
Carriers implemented NCCI edits within their claim processing systems for dates of service on or after January 1, 1996.
A subset of NCCI edits is incorporated into the outpatient code editor (OCE) for OPPS and therapy providers (Skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech-language pathology providers (OPTs), and home health agencies (HHAs) billing under TOBs 22X, 23X, 75X, 74X, 34X).
The purpose of the NCCI edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table have been combined into one table and include code pairs that should not be reported together for a number of reasons explained in the Coding Policy Manual.
The Correspondence Language Manual available below has been written and maintained for utilization by the Medicare Contractors to answer routine correspondence inquiries about the NCCI procedure to procedure and MUE edits. The general correspondence language paragraphs explain the rationale for the edits. The section-specific examples add further explanation to the NCCI or MUE edits and are sorted by edit rationale and CPT code section (00000, 10000, 20000, etc.). Please refer to the Introduction of this Manual for additional guidance about its use.
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