Know your NCCI edits to ensure correct insurance claims coding.

The National Correct Coding Initiative (NCCI) is a claims editing process constructed by the Centers for Medicare and Medicaid (CMS). If you are submitting claims to insurers, you need to know about NCCI in order to code claims correctly. Not understanding NCCI edits can negatively affect your reimbursement.

This edits program was started about 10 years ago, as a way to prevent Medicare administrative contractors (MACs) from paying for duplicative or overlapping services, and to encourage compliant coding. Often called “Column One/Column Two” edits, they are largely based on Current Procedural Terminology (CPT®) coding rules, on the Medicare fee schedule’s relative value system, and on national and local health insurance policies and claims edits.

The “Column One/ Column Two” name is literal; the edits are presented in a spreadsheet with the affected codes listed in the first two columns. The edits specify which CPT code pairs should not be coded together — and will not be reimbursed — if the codes are billed for the same patient, on the same day, by the same provider.

When two edited codes are billed together, only the code in Column One will be reimbursed. The code in Column Two will be denied.

For example, codes 90791 (psychological evaluation) and 96116 (neurobehavioral status exam) are considered similar enough that they shouldn’t both be reported or paid for the same patient, on the same day, by the same provider. In this case, 90791 is the “Column One” code and is reimbursable, while 96116 — the Column Two code — is not.

NCCI edits are applied to every health care specialty and are publically available in a downloadable spreadsheet from CMS. The spreadsheet is updated every quarter, and national health care specialty organizations such as the APA Practice Organization have the opportunity to review and comment on edits before they are published. APA’s Office of Health Care Financing (OHCF) works with a team of experts to review and discuss all NCCI edits that could be problematic for reimbursement of psychology and neuropsychology services.

OHCF has been successful in modifying particular edits; in other cases, we were able to prevent edits from being published — as we were able to demonstrate that the edit would be contrary to current practice.

For example, in 2015, individual psychotherapy (90832, 90834 or 90837) and family psychotherapy (90847) could not be billed together. OHCF explained to CMS that there are clinically appropriate times when a patient might be seen as an individual and as part of a family on the same day. CMS agreed with our argument and changed the edit to allow an override modifier.

If extenuating circumstances require individual and family therapy on the same day, psychologists can add CPT modifier -59 to one of the billed codes. Modifier 59 denotes that the two services are “separate and distinct” without overlap in services. Psychologists who use a CPT modifier should be prepared to submit documentation to support its use.

Additionally, implementation of the change was retroactive to its implementation date — meaning that claims that had been denied were reprocessed and considered for full payment.

Use of the NCCI edits has spread beyond the Medicare and Medicaid programs. Many commercial insurers also use the NCCI to prevent overpayments in their claims. Check with the insurer to determine if the edits are in effect for the patient’s policy.

Additional resources:

If you have additional questions about NCCI edits, contact Coding and Payment Policy Officer Debra Lansey via email.

This article is part of a series from the Practice Organization and the Office of Health Care Financing to help members understand the process and work that goes into establishing payment rates, both in Medicare and other third party insurers.

Current Procedural Terminology (CPT®) copyright 2015 American Medical Association. All rights reserved.