NCCI Edits explained

In 1996, CMS Implemented National Correct Coding Initiative (NCCI). 

It has 2 major goals:      

 - To promote physician and provider compliance with medicare diagnosis and procedure coding guidelines.

  -   To ensure appropriate payment (reimbursement) for physician and provider services.

NCCI edits identify invalid diagnosis codes such as (ICD-9-CM) E codes, and discrepancies between the diagnosis and the patient’s age or sex. For eg, a claim submitted for a male patient with a code for ovarian failure or a female patient with prostate hypertrophy, will be returned to the provider without payment.

NCCI edits identify following types of procedure coding errors:

1.       Mutually Exclusive Procedures:- reporting 2 procedures that cannot possibly be performed at the same time, such as laminectomy (removal of the bony arches of a vertebrae) and total hip replacement.

2.       Component part coding:- submitting separate or multiple codes for a procedure that is covered by a single code, such as reporting a separate code for a laprotomy (incision into abdomen) that was done as a part of appendectomy.

3.       Unbundling:- submitting separate or multiple codes that are part of a global surgery package such as routine post operative surgeries.

4.       Invalid Modifier:- assigning a wrong modifier to the CPT or a HCPCS Level II code. For eg. 52, Reduced Services applies only to procedure/services provided on an inpatient basis and may not be assigned to outpatient or ASC procedure codes.