In the intricate world of healthcare, maintaining accuracy and consistency in medical coding is paramount. National health care coding standards are the backbone of this consistency, ensuring proper claim processing and preventing incorrect payments. The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) program to promote these national standards specifically for Medicare Part B claims. CMS retains ownership and decision-making authority over all aspects of the NCCI program, underscoring its importance in upholding national health care coding standards.
CMS formulates its coding policies based on a comprehensive set of resources. These include the coding conventions outlined in the American Medical Association’s Current Procedural Terminology (CPT) Manual, a compilation of national and local coding policies and edits, and coding guidelines developed by respected national medical societies. Furthermore, CMS incorporates analysis of standard medical and surgical practices and reviews current coding practices to ensure NCCI aligns with the evolving landscape of healthcare and national health care coding standards.
NCCI Implementation: Procedure to Procedure (PTP) Edits and Medically Unlikely Edits (MUEs)
The NCCI program employs several key tools to maintain national health care coding standards. Among these are the Procedure to Procedure (PTP) edits, designed to prevent improper payments arising from incorrectly reported combinations of codes. NCCI maintains separate PTP edit tables for physicians/practitioners and for outpatient hospital services, acknowledging the different coding contexts within healthcare. These edits are a critical component of ensuring adherence to national health care coding standards.
Complementing PTP edits are the NCCI Medically Unlikely Edits (MUEs). MUEs address a different dimension of coding accuracy by preventing improper payments when services are reported with incorrect units of service. By setting limits on the maximum units of service payable under specific codes in particular contexts, MUEs contribute to the overall integrity of national health care coding standards. For detailed guidance on utilizing these tools, refer to the How to Use NCCI Tools booklet (PDF).
Medicare Administrative Contractors (MACs) are responsible for implementing NCCI PTP edits within their claim processing systems. CMS also integrates PTP edits into the outpatient code editor (OCE) for the Outpatient Prospective Payment System (OPPS), ensuring consistent application of national health care coding standards across outpatient hospital services and other facility services. These services encompass a broad range of providers, including therapy providers (Part B Skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech-language pathology providers (OPTs), and certain claims for home health agencies (HHAs) billing under specific Type of Bills (TOBs) codes. Similarly, MACs implement MUE edits and corresponding edits within the Fiscal Intermediary Shared System (FISS), reinforcing the nationwide adoption of national health care coding standards.
Replacement Files and Updates to Coding Standards
To keep pace with changes in medical practice and coding guidelines, NCCI regularly updates its PTP and MUE files on a quarterly basis. These updates are essential for maintaining the relevance and accuracy of national health care coding standards. Occasionally, situations necessitate changes outside the standard quarterly schedule, leading to the issuance of replacement files.
- January 29, 2025 – Replacement Files (1st Quarter, 2025): CMS issued replacement files for NCCI Medicare MUE (PRA/OPH/DME) to revise the MUE value for Healthcare Common Procedure Coding System (HCPCS) code J0911, effective January 1, 2025. These updated files are publicly accessible, reflecting ongoing refinements to national health care coding standards.
- Sep 14, 2023 Replacement Files (4th quarter of 2023): CMS released replacement files for NCCI Procedure to Procedure (PTP) edits for the October 1, 2023 files (PRA and OPH). This update involved the temporary implementation and subsequent withdrawal of PTP edits between certain presumptive and definitive drug testing codes, demonstrating the dynamic nature of national health care coding standards and the responsiveness of CMS to coding practice feedback.
- Further updates in 2023 and 2022 also highlight the continuous evolution of NCCI edits to reflect current medical practices and maintain national health care coding standards.
Contact Information for NCCI Program Inquiries
For general inquiries and concerns regarding the NCCI program and its edits related to national health care coding standards, the NCCI program is available to assist. However, it is important to direct claim-specific inquiries, including appeals of NCCI-related denials, to the relevant Medicare Administrative Contractors (MACs).
The NCCI program’s scope is limited to NCCI-related matters and does not extend to other CMS programs or payors. Questions regarding Local Coverage Determinations, code descriptor or status indicator changes, or modifiers unrelated to NCCI fall outside their purview.
Valuable resources, including edit files, the Medicare NCCI Policy Manual, FAQs, and supplementary information, are readily available on the NCCI webpages. Please note that CMS does not offer a code look-up service or a clean claims tool.
Written inquiries about the NCCI program, encompassing PTP, MUE, and Add-on Code edits and their role in national health care coding standards, can be submitted via email to [email protected].
**NOTE** It is crucial to avoid including any Personally Identifiable Information (PII) or Protected Health Information (PHI) in your communications.
Submitting an Appeal for NCCI-Related Denials
Appeals related to NCCI denials must be submitted to your responsible MAC or Qualified Independent Contractor (QIC), not directly to the NCCI Contractor. Detailed instructions for filing an appeal can be found on the Appeals website. The NCCI contractor is not authorized to process claim-specific appeals or forward appeal submissions to the appropriate appeals contractor.
By understanding and adhering to national health care coding standards and programs like NCCI, healthcare providers can ensure accurate claim submissions, reduce improper payments, and contribute to the financial integrity of the healthcare system.
