2 Types of NCCI Edits

NCCI contains two types of edits: mutually exclusive and comprehensive/component edits. Knowing the difference between these types of edits can benefit your practice.

Mutually exclusive edits pair procedures or services that the physician would not reasonably perform at the same session, at the same anatomic location, on the same beneficiary.

A good example is using 76828 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study) is a component of 76820 (Doppler velocimetry, fetal; umbilical artery) and 76821 (… middle cerebral artery), thanks to an NCCI mutually exclusive edit.

However, if you were to report two mutually exclusive codes for the same patient during the same session, Medicare would reimburse only for the lesser valued of the two procedures. In this case, 76828 is the lesser valued procedure.

Comprehensive/component edits describe bundled procedures. That is, CMS considers the code listed in column 2 as the lesser service, which is included as a component of the more extensive column 1 procedure. When you are compiling your medical billing claims you would need to report those as lesser procedures.

A great example of comprehensive/component edits is NCCI contains an edit that bundles moderate sedation codes (99143-99149) into 58823 (Drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous [e.g., ovarian, pericolic]). In this case, 58823 is the more extensive procedure, which includes the lesser procedure — any one of the moderate sedation codes (99143-99149). The moderate sedation is an inherent part of the procedure when performed by the same physician performing the procedure.

If you were to report bundled (comprehensive/component) procedures for the same patient during the same session, Medicare would reimburse only for the higher value of the two procedures (in this case, 58823).

In certain cases you can override NCCI edits but only after checking the correct coding modifier and being certain each indicator for the NCCI has a 0 or 1 designation. A “0” indicator means that you may not unbundle the edit combination under any circumstances, according to NCCI guidelines.

An indicator of “1,” however, means that you may use a modifier to override the edit if the procedures are distinct from one another (for instance, if they occur in separate anatomic locations).

Using this simple method to determine the best returns on your medical billing where NCCI edits are concerned, will help your practice realize a better reimbursement for your services.

View all Articles by: Melissa Clark, CCS-P