CMS National Correct Coding Initiative Edits

A revised annual version of the National Correct Coding Initiative Policy Manual for Medicare Services, effective January 1, 2022, was posted December 15, 2021.
 
Additions/revisions to the manual are noted in red font.
 
Additional prior versions of the National Correct Coding Initiative Policy Manual for Medicare Services are now available on this page in the NCCI Policy Manual Archive.

National Correct Coding Initiative Announcements

• Effective January 1, 2022, CMS implemented a new format for the Add-On Code (AOC) edit file. The format is a fixed-width text file (link to file structure (PDF)

Replacement Files

The CMS issued replacement files with the following changes:

• Replacement Files (1st quarter of 2022) - CMS issued a second set of replacement files for NCCI Procedure to Procedure (PTP) edits for the January 1, 2022 files. Updated public replacement files for Medicare are available using the links in the left navigation pane. (Announcement posted February 02, 2022)
• Replacement Files (1st quarter of 2022) - CMS issued replacement files for NCCI Procedure to Procedure edits (PTPs) and Medically Unlikely Edits (MUEs) for the January 1, 2022 files. Updated public replacement files for Medicare are available using the links in the left navigation pane. (Announcement posted December 14, 2021)
• Replacement Files (4th quarter of 2021, V2) - CMS issued replacement files for NCCI PRA Procedure to Procedure (PTP) for the October 1, 2021 files. Updated public replacement files for Medicare are available using the links in the left navigation pane. (Announcement posted October 1, 2021)
• Replacement Files (1st quarter of 2021) - CMS issued replacement files for NCCI Medically Unlikely Edits (MUEs) for the January 1, 2021 files. Updated public replacement files for Medicare are available using the links in the left navigation pane. (Announcement posted December 14, 2020)
• Replacement MUE Files (3rd quarter of 2020) - CMS issued replacement files for NCCI MUE PRA and NCCI MUE OPH to update Medically Unlikely Edits (MUEs) for Healthcare Common Procedure Coding System (HCPCS) codes G2078 and G2079 retroactive to July 1, 2020. Updated public replacement files for Medicare are available using the links in the left navigation pane. (Announcement posted August 12, 2020)
• Replacement Files (2nd quarter of 2020) – related to the COVID-19 Public Health Emergency:
  In accordance with Centers for Medicare & Medicaid Services’ (CMS) expansion of telehealth services, CMS updated procedure-to-procedure (PTP) edits and Medically Unlikely Edits (MUEs) for Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes. CMS issued replacement files for NCCI PTP PRA, NCCI PTP OPH, NCCI MUE PRA, and NCCI MUE OPH.
  
  Per CMS’ announcement, effective for services starting March 6, 2020, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances. Although NCCI files have dates consistent with the first day of each quarter and are therefore dated retroactively to January 1, 2020, payments based on the expansion of telehealth services are for dates of services starting March 6, 2020. CMS provided a complete list of all Covered Telehealth Services for PHE for the COVID-19 pandemic.
  
  Physicians, hospitals, and other providers must report services correctly and code correctly even in the absence of NCCI or OCE edits. (Announcement posted May 14, 2020; Announcement updated September 3, 2020)
• CMS is temporarily deleting procedure-to-procedure (PTP) edits with several radiopharmaceuticals retroactive to January 1, 2020. (Announcement posted February 28, 2020)
• Healthcare Common Procedure Coding System (HCPCS) codes G2061, G2062, and G2063 replaced G2029, G2030, and G0231 respectively, effective January 1, 2020. (Announcement posted February 4, 2020)
• CMS made the decision to retain the edits that were in effect prior to January 1, 2020, and to delete January 1, 2020, PTP edits for Current Procedural Terminology (CPT) code pairs 97530 or 97150/97161, 97530 or 97150/97162, 97530 or 97150/97163, 97530 or 97150/97165, 97530 or 97150/97166, 97530 or 97150/97167, 97530 or 97150/97169, 97530 or 97150/97170, 97530 or 97150/97171, and 97530 or 97150/97172 (Announcement posted February 4, 2020)

Updated files are available on the PTP Coding Edit webpage and the Quarterly PTP and MUE Version Update Changes webpage.

National Correct Coding Initiative

The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents. The CMS developed its coding policies 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 a review of current coding practices. The CMS annually updates the National Correct Coding Initiative Policy Manual for Medicare Services. The NCCI Policy Manual should be used by Medicare Administrative Contractors (MACs) as a general reference tool that explains the rationale for NCCI edits.

MACs implemented NCCI PTP edits within their claim processing systems and CMS incorporated PTP edits into the outpatient code editor (OCE) for OPPS. These edits are applied to outpatient hospital services and other facility services including, but not limited to, therapy providers (Part B Skilled nursing facilities (SNFs)), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech-language pathology providers (OPTs), and certain claims for home health agencies (HHAs) billing under TOBs 22X, 23X, 75X, 74X, 34X. MACs implemented Medically Unlikely (MUE) edits and corresponding MUE edits are similarly implemented within the Fiscal Intermediary Shared System (FISS).

The purpose of the NCCI PTP edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services. The purpose of the NCCI MUE program is to prevent improper payments when services are reported with incorrect units of service. Refer to the How to Use NCCI Tools booklet (in the Downloads section below) for more information.

CMS wrote the Correspondence Language Manual (in the Downloads section below) and maintains it for use by the MACs to answer routine correspondence inquiries about the NCCI PTP and MUE edits. The general correspondence language paragraphs explain the rationale for the edits. The section-specific examples add further explanation to the PTP or MUE edits and are sorted by edit rationale and CPT code section (00000, 10000, 20000, etc.). Please refer to the Introduction of this Manual for additional guidance about its use.

Inquiries about the NCCI program, including those related to NCCI (PTP, MUE and Add-On Code) edits, should be sent to the following email address: NCCIPTPMUE@cms.hhs.gov.

The NCCI contractor is able to address questions and concerns about NCCI edits and the program in general. However, because NCCI edits are implemented by the MACs as part of routine claim processing, claim-specific inquiries must be made to the MAC. This includes appeals of NCCI-related claim denials. 

Appeals must be submitted to your responsible MAC or QIC, not the NCCI Contractor. To file an appeal, please follow instructions on the Appeals website. The NCCI contractor cannot process specific claim appeals, and cannot forward appeal submissions to the appropriate appeals contractor.

 **NOTE** Any submissions made to the NCCI contractor that contain Personally Identifiable Information (PII) or Protected Health Information (PHI) are automatically discarded, regardless of the content, in accordance with federal privacy rules with which the NCCI Contractor must comply.

This web page provides information to providers on Medicare's NCCI edits but does not address specific NCCI edits. If the viewer has concerns about specific NCCI edits, they may submit comments in writing to:

National Correct Coding Initiative Contractor
Email: NCCIPTPMUE@cms.hhs.gov
P.O. Box 246
Pittsford, NY 14534

Fax #: 1 (585) 510-7234