If a Procedure Code or combination of Procedure Codes violates NCCI edits, a $0 OMFS reimbursement will display. View the CCI Edits section of the Procedure Code’s Detailed Information for specifics about the NCCI violation.
A. § 9789.12.1. Physician Fee Schedule: Official Medical Fee Schedule for Physician and Non-Physician Practitioner Services - For Services Rendered On or After January 1, 2014.
Per the Official Medical Fee Schedule § 9789.12.1 for Physician and Non-Physician Practitioner Services, the OMFS Calculator incorporates the following fee-affecting reimbursement rules:
- Physician National Correct Coding Initiative Edits (NCCI) Edits: adopted by the CMS for payments for medical services under the Physician Fee Schedule
- Practitioner Services Medically Unlikely Edit (MUE) Table: Medically Unlikely Edits are published by CMS
B. Physician National Correct Coding Initiative Edits (NCCI) Edits
NCCI Edits occur when services should not be reported together.
- Each edit has a column one and column two procedure code. If a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment.
C. Practitioner Services Medically Unlikely Edit (MUE) Table
MUEs prevent payment for an inappropriate number/quantity of the same service on a single day. MUEs are adjudicated either as claim line edits or DOS edits.
- If the MUE is adjudicated as a claim line edit, the units of service (UOS) on each claim line are compared to the MUE value for the procedure code on that claim line. If the UOS exceed the MUE value, all UOS on that claim line are denied.
- If the MUE is adjudicated as a DOS MUE, all UOS on each claim line for the same date of service for the same procedure code are summed, and the sum is compared to the MUE value. If the summed UOS exceed the MUE value, all UOS for the procedure code for that date of service are denied.
D. Learn more about NCCI Edits:
CMS National Correct Coding Initiative Policy Manual For Medicare Services
NCCI Edits cover many different correct coding topics, including:
- Misuse of column two code with column one code
- HCPCS/CPT procedure code definition
- Sequential procedure
- CPT "separate procedure" definition
- Anesthesia service included in surgical procedure
- More extensive procedure
- CPT Manual or CMS manual coding instructions
- Standards of medical / surgical practice
- Gender-specific (formerly Designation of sex) procedures
- Standard preparation / monitoring services for anesthesia
- Laboratory panel
- Mutually exclusive procedures
- MUEs
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