NCCI Implementation
Replacement Files
Contact Information
Submitting an Appeal
CMS developed the NCCI program to promote national correct coding of Medicare Part B claims. CMS owns the NCCI program and is responsible for all decisions regarding its contents.
CMS develops its coding policies based on coding conventions defined in the American Medical Association’s Current Procedural Terminology (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.
NCCI Implementation
The purpose of the NCCI Procedure to Procedure (PTP) edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians or practitioners and one table of edits for outpatient hospital services. The purpose of the NCCI Medically Unlikely Edits (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 (PDF) for more information.
MACs implement NCCI PTP edits within their claim processing systems, and CMS incorporates PTP edits into the outpatient code editor (OCE) for the Outpatient Prospective Payment System (OPPS). These edits apply 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 Type of Bills (TOBs) 22X, 23X, 75X, 74X, 34X. MACs similarly implement Medically Unlikely (MUE) edits and corresponding MUE edits within the Fiscal Intermediary Shared System (FISS).
Replacement Files
- Sep 14, 2023 Replacement Files (4th quarter of 2023) – CMS issued replacement files for NCCI Procedure to Procedure (PTP) edits for the October 1, 2023 files (PRA and OPH).Effective July 1, 2023, CMS implemented NCCI PTP edits between Column One codes 80305, 80306, and 80307 for presumptive test(s), and Column Two codes G0480 – G0483, and G0659 for definitive test(s). CMS will withdraw these edits retroactive to July 1, 2023 in a replacement file for the 4th quarter of 2023. The MACs will adjust those claims with dates of service between July 1, 2023 and October 1, 2023 to allow payment as appropriate under existing payment and coverage policies. Alternatively, a laboratory may also choose to use the MAC appeals process if it does not wish to wait for the automatic adjustment to occur, or it can wait to submit its claims until CMS implements the change.
- Effective July 1, 2023, CMS implemented bypassable NCCI PTP edits between Column One codes 22630, 22632, 22633 and 22634, and Column Two codes 63052 and 63053. CMS will delete these edits in the October 1, 2023 edit files. The MACs will adjust claims with dates of service between July 1, 2023 and October 1, 2023 that were denied due to lack of a modifier to allow payment. A provider may also choose to use the MAC appeals process if it does not wish to wait for the adjustment to occur, or it can wait to submit its claims until CMS implements the change.
- NCCI updates the PTP and MUE files on a quarterly basis. However, there may be instances in which a change is needed outside of those quarterly timeframes and a replacement file is necessary. CMS issued replacement files with the following changes:
- Dec. 7, 2022 - Replacement Files (1st quarter of 2023) - CMS issued replacement files for NCCI Procedure to Procedure (PTP) edits and updated for the January 1, 2023 files (PRA and OPH).
Contact Information
The NCCI program may address general questions and concerns about the NCCI program and edits. You must submit claim-specific inquiries to the Medicare Administrative Contractors (MACs). This includes appeals of NCCI-related denials; see Submitting an Appeal below.
The NCCI program cannot answer questions outside of our scope, or questions about other CMS programs or about other payors. For example, we cannot answer questions about Local Coverage Determinations, changes to code descriptors or status indicators, or modifiers not associated with NCCI.
The NCCI webpages include edit files, the Medicare NCCI Policy Manual, FAQs, and additional information. CMS does not provide a look-up service or a clean claims tool.
You may submit inquiries about the NCCI program, including those related to NCCI (PTP, MUE, and Add-on Code) edits, in writing via email toNCCIPTPMUE@cms.hhs.gov.
**NOTE** Don’t submit any Personally Identifiable Information (PII) or Protected Health Information (PHI).
Submitting an Appeal
You must submit appeals to your responsible MAC or QIC, not the NCCI Contractor. To file an appeal, please follow the instructions on theAppeals website.The NCCI contractor cannot process specific claim appeals and cannot forward appeal submissions to the appropriate appeals contractor.
Helpful Educational Materials
- How to Use The National Correct Coding Initiative (NCCI) Tools (PDF)
- Revised Modification to the Medically Unlikely Edit (MUE) Program -R1421OTN (PDF)
- Proper Use of Modifiers 59, XE, XP, XS, and XU (PDF)
- Medicare NCCI Correspondence Language Manual- Posted February 28, 2023
- Revised Modification to the Medically Unlikely Edit (MUE) Program - MM8853 (PDF)
- SE1422 - Medically Unlikely Edits (MUE) and Bilateral Surgical Procedures (PDF)
Related Links
- The National Correct Coding Initiative in Medicaid
- HCPCS - General Information
