Getting to Know the NCCI Manual Beyond The Edits

Thu, Apr 28, 2016 --


ncci guidelines, ncci edits, medicaid modifiers, medicare ncci edits, medicare cci edits

We’ve talked about CCI edits a lot in this blog, but how well do you know the NCCI Coding Policy Manual itself?

According to Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, the National Correct Coding Initiative is much more than just edits. CMS developed its National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual for short) as a set of guidelines and policies intended to promote national correct coding methods and control improper coding. While edits are released every quarter, CMS publishes the manual itself once a year on January 1. When the manual is updated each year, the changes are presented in an italicized, red font. You can download the January 2016 edition here.

Huey explained that the guidelines in CMS’s Coding Policy Manual are binding on Medicare and its payers, but not necessarily any other payer you may bill to, so it’s important to check with your payers to see if they follow the NCCI edits.

“It’s a good thing when payers do follow these edits,” Huey said, “because then the edits are published and you know what the payer follows.” She added that coders in her state were happy when the state’s largest payer decided to follow NCCI edits. “This was great news for us because we no longer had to guess at what they were doing,” she said.

Manual Language — ‘Physician’ Includes Hospitals, Too

Because the NCCI guidelines were originally developed in the 1990s for physicians and were later applied to hospitals and other entities as well, some of the language in the manual can be confusing. The Manual itself warns of this in chapter 1, explaining “In this Manual many policies are described utilizing the term ‘physician.’ Unless indicated differently the usage of this term does not restrict the policies to physicians only but applies to all practitioners, hospitals, providers, or suppliers eligible to bill the relevant HCPCS/CPT codes.”

The main difference between physician coding and hospital-based coding? Professional (physician) coding is based on what the physician does, while on the facility side, coding is mainly based on resource utilization.

How About You?

The 2016 NCCI Coding Manual made some changes in modifier billing guidelines, especially for modifier 59 and time blocks. Have CCI changes affected the way your practice bills? Let us know in the comment box below.

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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