Health Information Management

Q&A: Determine whether your third-party payers can process outpatient claims against the NCCI edits

APCs Insider, June 6, 2008

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QUESTION: Do the National Correct Coding Initiative (NCCI) unbundling prohibitions apply to payers other than CMS?
 
ANSWER: CMS developed the NCCI to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Part B claims. The coding policies are based on coding conventions defined in the American Medical Association’s (AMA) CPT Manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, and/or current coding practice.
 
Although the NCCI was initially developed for use by Medicare carriers to process Part B claims, CMS added many of the edits to the Outpatient Code Editor (OCE) in August, 2000 for use by fiscal intermediaries (FI) to process claims for Part B outpatient hospital services. Some of the edits applied to outpatient hospital claims through the OCE differ from the comparable edits in NCCI. All NCCI edits are incorporated in the Integrated OCE (I/OCE) with the exception of:
 
  • Anesthesiology
  • Evaluation and management
  • Mental health
  • Certain drug administration code pairs
Effective January 2006, all therapy claims paid by FIs were also subject to NCCI edits in the OCE. As of April 1, 2008, version 14.0 is required and utilized for outpatient claims submission. We advise our readers to check their technology to ensure that correct versions are in place for the outpatient revenue cycle. 
 
NCCI edits are based on AMA CPT coding conventions and standard medical and surgical practices. Due to Medicare's requirements that hospitals must bill the same charge for the same service to all payers, correct coding rules should apply to all outpatients regardless of payer. However, not all third-party payers have the capabilities to process outpatient claims against the NCCI edits. In addition, third-party payers may apply physician NCCI edits to hospital claims. We advise our readers to research the top payers within their outpatient revenue cycle to determine if appropriate edits are being applied.



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