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National Correct Coding
by Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P
The Centers for Medicare and Medicaid Services (CMS) has
developed a list of coding edits an effort to promote correct coding
nationwide and to prevent the inappropriate unbundling of related
services. The National Correct Coding Initiative (NCCI) edits help
CMS detect inappropriate codes submitted on claims that are based
on CPT coding guidelines, current standards of medical or surgical
coding practice, and advice from specialty societies. There are
three major types of coding edits: the comprehensive/component
edit, the mutually exclusive edit, and the medical unlikely edit.
The comprehensive/component edit pertains to HCPCS codes that should
not be used together. The following is an example of a NCCI listing:
Comprehensive Code Component
20912 12014, 13152
Under the NCCI, if bills contain
a procedure in both the comprehensive code column and the component
code column for the same patient on the same date of service, only
the code in the comprehensive code column is covered (provided
that code is on the list as an approved procedure for reimbursement).
In the preceding example, code 20912 describes
a cartilage graft of nasal septum. During the procedure, the surgeon
may mention that a wound repair (12014, 13152) was performed, but
it is considered part of the more involved procedure (20912) and
should not be coded. If the coding professional assigned the additional
wound repair codes, it would be considered unbundling.
Mutually Exclusivet Edit
The mutually exclusive edit applies to improbable
or impossible combinations of codes. For example, code 69601, Revision
mastoidectomy; resulting in complete mastoidectomy, would never
be performed with code 69604, Revision mastoidectomy; resulting
NCCI edits are included in most encoding software
packages. The software vendors are responsible for maintaining
up-to-date edits to support the coding/billing function. More information
about NCCI edits can be found on the CMS Web site.
Medically Unlikely Edit
For Part B claims, CMS has developed “medical
unlikely edits” to reduce error rates for items on the claim form
that reference units of service. For each HCPCS/CPT code, the edits
list the maximum units of service that a provider would report
under most circumstances for a single beneficiary on a single date
Smith, Gail. Basic Current Procedural Terminology
and HCPCS Coding, 2010 Edition. Chicago, IL: AHIMA, 2010.
Melanie Endicott (email@example.com)
is a practice resources specialist at AHIMA.