2017-53: National Correct Coding Initiative Reminder

Date: 10/11/17

As a reminder, Louisiana Healthcare Connections uses the National Correct Coding Initiative standard claim edits developed by the Centers for Medicare & Medicaid Services (CMS) in order to correctly adjudicate both physical and behavioral health claims.

How does this currently impact claims?

All adjudicated claims are processed using NCCI standard claim edits. This complies with the federal Patient Protection and Affordable Care Act signed into law in March 2010.  The coding edits impact the following claim types:

• Professional and outpatient facility claims submitted on the CMS-1500 form
• Outpatient facility claims submitted on the UB-04 (CMS-1450) form

Note: The NCCI edits apply regardless of the format in which a claim is submitted (e.g., paper, electronic or web-based submissions).

What are the types of NCCI edits?

The National Correct Coding Initiative contains two types of edits:

1. NCCI Procedure-To-Procedure (PTP) edits that define pairs of Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons. The purpose of the PTP edits is to prevent improper payments when incorrect code combinations are reported.
2. Medically Unlikely Edits (MUEs) define for each HCPCS / CPT code the maximum units of service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service.