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NCCI Edits

Getting a CCI Edit warning? Don’t worry. Here’s how to fix the error.

First, what is a CCI Edit? California’s Official Medical Fee Schedule, in § 9789.12.1 for Physician and Non-Physician Practitioner Services, specifies that reimbursements must incorporate these fee-affecting rules:

  • Physician CCI Edits: National Correct Coding Initiative Edits (“NCCI”) adopted by the CMS for payments for medical services under the Physician Fee Schedule
  • NCCI Edits affect allowable combinations of different procedure codes
  • Practitioner Services MUE Table: Medically Unlikely Edits published by the CMS
  • MUE edits affect the number of allowable units of a procedure code

Since claims administrators may deny reimbursement for the procedure codes that violate either of these rules, DaisyBill alerts you if any CCI errors. Depending on the rule violation, correct the bill by doing one of the following:

  • Adding an appropriate modifier
  • Selecting a different procedure code, or
  • Editing the number of reported units

Step 1.  From the Add Bill Page, enter required information and click ‘Create Bill,’ then review for a CCI Edit warning

If the Expected column shows $0 and a red CCI Edits warning appears next to the procedure code, then the bill violates CCI edits.

Step 2.  Click the red CCI Edit Warning

Clicking the red CCI Edits box displays detailed information about the CCI Edit or MUE error.

CCI Edits occur when services are incorrectly billed together.

  • The NCCI includes code pair edits, where each edit has a column one and column two HCPCS / CPT 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.

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 HCPCS/CPT 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 Date Of Service (DOS) MUE, all UOS on each claim line for the same date of service for the same HCPCS/CPT code are summed, and the sum is compared to the MUE value. If the summed UOS exceed the MUE value, all UOS for the HCPCS/CPT code for that date of service are denied.

Step 3.  Review the CCI Edit details, click ‘Edit Bill,’ then correct the coding

Below is an example of a MUE error which prevents payment for an inappropriate number/quantity of the same service on a single day.

Step 4.  Check the CCI Edit Warning

A corrected warning turns green and displays an Expected amount.

Step 5.  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

That’s a lot to digest, we know.

To sum up: Daisybill shows red CCI Edit Warnings when it detects coding errors. When the coding is corrected, the red error message turns green.

Then you can submit the bill.

Sound good?

Good!

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