Ways to minimize NCCI denial risk.
NCCI denial risk: Becoming knowledgeable about National Correct Coding Initiative (NCCI) policies and edits may be the difference between having a profitable revenue cycle or placing your facility at risk for denials. In recent years, NCCI policies and edits have become key factors in outpatient facility and professional claims denials. You must have a strong understanding of these guidelines to ensure coding compliance and to mitigate risk.
Follow NCCI Policy Manual Annual Updates:
The NCCI Policy Manual is updated annually. The new guidance becomes effective Jan. 1 of each year.
Special attention should be paid to claims denied during the first quarter of the year to ensure you are consistent with the most recent published guidelines.
NCCI Edits Are Updated Quarterly:
NCCI edits are updated quarterly and are effective Jan. 1, April 1, July 1, and Oct. 1 each year. Because the NCCI Policy Manual is updated only annually, the quarterly updates may not correlate with the information published in the NCCI Policy Manual.
The July 2016 NCCI updates eliminated the procedure-to-procedure code edits precluding the assignment of code 29823 Arthroscopy, shoulder, surgical; debridement, extensive with several other ipsilateral shoulder surgeries; however, the 2016 NCCI Policy Manual maintained the following language, ?With the exception of the knee joint, arthroscopic debridement should not be reported separately with a surgical arthroscopy procedure when performed on the same joint at the same patient encounter.?
In this case, the encoder would no longer flag the debridement as not separately reportable by the procedure-to-procedure edits, but the language in the NCCI Policy Manual would still preclude the assignment of a debridement code with another ipsilateral arthroscopic shoulder surgery.
The quarterly updates must be reviewed when they are published and compare them to the guidance published in the NCCI Policy Manual.
Not Every NCCI Policy Guideline Has an Edit
You may think that, if there isn?t an edit to preclude a particular code assignment, you can combine codes as you please.
One should remember that not every NCCI policy has an associated NCCI edit. Per the NCCI Policy Manual, ?Providers are obligated to code correctly even if edits do not exist to prevent the use of an inappropriate code combination.?
Become familiar with guidelines published in the NCCI Policy Manual. Do not rely on your encoder, alone, to flag NCCI edit violations for code pairs.
CPT(R) Assistant Versus NCCI Policy Guidance
One may encounter cases where the guidance published in the NCCI Policy Manual differs from that published in CPT(R) Assistant. When this occurs, establish which set of guidelines has precedence.
For Medicare claims, the NCCI policies prevail. According to page I-28 of the NCCI Policy Manual:
The American Medical Association publishes CPT(R) Assistant which contains coding guidelines. CMS does not review nor approve the information in this publication.
In the development of NCCI PTP edits, CMS occasionally disagrees with the information in this publication. If
a physician utilizes information from CPT(R) Assistant to
report services rendered to Medicare patients, it is possible that Medicare Carriers (A/B MACS processing practitioner service claims) and Fiscal Intermediaries may utilize different criteria to process claims.
For commercial claims, know whether the payer follows NCCI edits prior to code assignment to ensure compliance.
Apply Policies to Your Healthcare Organization
These are just a few of the potential risks your practice or facility may prevent by having a thorough understanding of the NCCI policies.
Coding managers should review the NCCI Policy Manual, and ensure their coding staff receives training on the sections applicable to their place of service.
The National Correct Coding Initiative (NCCI) was developed by the Centers for Medicare & Medicaid Services (CMS) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of Medicare Part B claims. Although the NCCI policies were initially established for the Medicare program, several commercial insurers have adopted it.