Is It Possible to Bypass or Avoid the NCCI Billing Edit?

The National Correct Coding Initiative (NCCI) is a program developed by the Centers for Medicare & Medicaid Services (CMS) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The NCCI contains edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together under any circumstances. The purpose of these edits is to prevent improper payments when certain code pairs are reported together.

Understanding the NCCI Billing Edit

The NCCI edits are based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and input from various sources.

There are two types of NCCI edits:

1. Column 1/Column 2 edit: This type of edit defines a mutually exclusive code pair. It indicates that the two codes should not be reported together for the same beneficiary on the same day by the same provider.
2. Column 1/Column 2 excludeds edit: This type of edit defines code pairs that should not be reported together unless a specific NCCI-associated modifier is used to bypass the edit.

Providers are expected to review the NCCI edits before submitting claims to ensure compliance with the coding guidelines. Failure to adhere to the NCCI edits can result in claim denials, recoupments, and potential audits by CMS.

Can the NCCI Billing Edit be Bypassed?

While the NCCI edits are designed to prevent improper payments, there are certain circumstances where providers may be able to bypass the edits by using appropriate modifiers. Modifiers are two-digit codes appended to CPT or HCPCS codes to provide additional information to payers about the services rendered.

When can the NCCI Billing Edit be Bypassed?

The NCCI-associated modifiers that can be used to bypass the edits include:

1. Modifier 59: This modifier is used to indicate that two services are separate and distinct from each other, and the provider has a VALID reason for reporting them together. Modifier 59 may be appended to the Column 2 code to bypass the edit.
2. Modifier 25: This modifier is used to indicate that a significant, separately identifiable evaluation and management (E/M) service was provided on the same day as another procedure or service. Modifier 25 may be appended to the E/M code to bypass the edit.
3. Modifier 51: This modifier is used to indicate that multiple procedures were performed during the same session or on the same day. Modifier 51 may be appended to the secondary procedure code to indicate that multiple procedures were performed.

Examples of Bypassing the NCCI Billing Edit

Here are a few examples of how providers can use modifiers to bypass the NCCI edits:

1. Provider performs a diagnostic colonoscopy (45378) and places a stent (43248) during the same session. Modifier 59 can be appended to the stent placement code (43248) to indicate that the services were performed separately and should be reimbursed accordingly.
2. Provider performs an E/M visit (99213) with a minor surgical procedure (17000) on the same day. Modifier 25 can be appended to the E/M code (99213) to indicate that a significant, separately identifiable E/M service was provided in addition to the procedure.

Avoiding NCCI Violations

While modifiers can be used to bypass the NCCI edits in certain situations, it is essential for providers to ensure that the use of modifiers is appropriate and supported by documentation. Improper use of modifiers can result in claim denials, audits, and potential recoupments by payers.

Providers can take the following steps to avoid NCCI violations:

1. Educate coding and billing staff on NCCI edits and appropriate modifier use.
2. Regularly review claims for NCCI violations and take corrective action when necessary.
3. Ensure that documentation supports the use of modifiers and justifies the medical necessity of the services rendered.
4. Stay updated on changes to the NCCI edits and coding guidelines to ensure compliance with current Regulations.

Conclusion

While the NCCI Billing Edit serves as an important tool to prevent improper payments and promote correct coding practices, providers may be able to bypass the edits in certain cases by using appropriate modifiers. It is crucial for providers to understand the NCCI edits, use modifiers judiciously, and ensure that documentation supports the use of modifiers to avoid claim denials and potential audits by payers.

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