Have you ever come across the term CCI edits or NCCI edits while managing the revenue cycle of your healthcare practice and wondered how these edits work? Here we are with our brand new blog which contains all the information you need to know about NCCI Edits

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NCCI edits, or National Correct Coding Initiative edits, are a set of rules and guidelines used to ensure proper coding and billing of medical procedures and services. These edits are maintained by the Centers for Medicare & Medicaid Services (CMS) and updated quarterly to provide up to date information. These edits are a set of guidelines which helps healthcare providers use appropriate and accurate codes when submitting claims for reimbursement.

NCCI edits help prevent fraud, errors, duplication and overpayments in the healthcare system by identifying code combinations that should not typically be billed together or require specific modifiers for proper billing. Health professionals use NCCI edits as a reference to ensure compliance with coding and billing rules.

History of National Correct Coding Initiative (NCCI) edits

The National Correct Coding Initiative (NCCI) edits were first implemented in January 1, 1996. NCCI policies and edits are designed to address procedures or services performed by the same provider for the same beneficiary on the same date of service.

How do NCCI edits work?

The National Correct Coding Initiative (NCCI) edits work by identifying and preventing improper coding and billing of medical procedures and services.

Code Pairing: NCCI edits primarily focus on pairs of Current Procedural

Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes. These code pairs are categorized as either “bundled” or “mutually exclusive.”

Bundled Codes: NCCI edits classify certain code pairs as “bundled,” meaning that the services represented by these codes should not typically be billed separately because they are considered components of a single comprehensive service. In such cases, only one of the codes in the pair should be billed.

Mutually Exclusive Codes: NCCI edits also identify code pairs that are considered “mutually exclusive.” This means that the two services represented by the codes should not be performed during the same patient encounter. If both services are provided, the provider must have a valid reason for doing so and may need to append specific modifiers to indicate the necessity.

Modifier Use: In some cases, healthcare providers may need to use specific modifiers to override the NCCI edits and justify the billing of both services in a bundled or mutually exclusive code pair. These modifiers provide additional information about the services provided.

Overall, the NCCI edits provide guidance to promote accurate and appropriate coding and billing practices, prevent overpayments or fraud, and ensure that healthcare services are billed in a manner consistent with established guidelines. Healthcare providers must be aware of these edits and use them as a reference to avoid billing errors, duplicate billing and compliance issues.