What is CCI edits in medical billing?

CCI edits in medical billing

FoodFindsAsia.com | What is CCI edits in medical billing?

CCI (Correct Coding Initiative)

The National Correct Coding Initiative (NCCI or CCI) is an automated edit system to control specific Current Procedural Terminology (CPT) code pairs that can be recounted on the same day. 

NCCI code pair edits are automated prepayment edit systems that prevent inappropriate payment when certain codes are submitted together for Part B-covered services. In addition to code pair edits, the NCCI also includes a set of edits known as “Medically Unlikely Edits” (MUEs).

MUE (Mutually Unlikely Edits)

 An MUE is a maximum number of Units of Service (UOS) that are allowed under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a health care provider on a date of service for a single recipient.

Standards

It was developed by the Centers for Medicare and Medicaid Services (CMS) for the consumption in all Medicare Part B and Medicaid claims, recently. The goal of CCI is to eliminate “mutually unlikely edits/ mutually exclusive” code pairings and codes considered to be the constituents of more comprehensive services or otherwise unauthentic to be delivered to the same patient on the same day. The CCI is updated on the quarterly basis.

Example

Code pairing like CPT 92607 (speech-generating device evaluation) and 92597 (voice prosthetic evaluation) is “mutually unlikely edits/ mutually exclusive”. Out Patient Code Editor (OCE) is the subset of CCI edits, which is applied to facility-based services, such as hospital casualty or SNF Part B services. Usually, the OCE edits for speech-language pathology are analogous to those in the CCI system. The OCE revisions also occur quarterly, but one quarter is implemented after the revised CCI edits.

Code Pair Edits

NCCI Edits-Physicians

These code pair edits are applicable to medical claims submitted by physicians, non-physician practitioners, and Ambulatory Surgery Centers (ASCs) that ASC procedures provide the list of the codes approved by Medicare. 

NCCI Edits-Hospital Outpatient Prospective Payment System (PPS)

This set of code pair edits is applied to the following subject to the Outpatient Code Editor (OCE): 

  • Hospitals Skilled Nursing Facilities (SNFs).
  • Home Health Agencies (HHAs) Part B
  •  Outpatient Physical Therapy and Speech-Language Pathology Providers (OPTs)
  •  Comprehensive Outpatient Rehabilitation Facilities (CORFs).

Medically Unlikely Edits

Practitioner MUEs

All physician and other health care practitioner claims are issued to these edits.

Durable Medical Equipment (DME) Supplier MUEs

These edits are applicable to claims submitted to DME MACs. At this time, this file includes HCPCS A-B, D-H, and K-V codes along with HCPCS codes under the DME MAC jurisdiction.

Facility Outpatient MUEs

Critical Access Hospitals are issued to medically unlikely edits.

Responsibility of professional coder

The Certified Professional Coder contributes in generating revenue by assigning and monitoring the medical coding procedures and reimbursement activities for professional and health care technical services provided within an industry of specialty areas. They directly assign ICD-9 and ICD-10 codes by analyzing patient’s health care services records. They ensure documentation by collection providers to conform legal and procedural requirements along with the research of denied claims.

SHARE