Description

This policy outlines how Blue Cross NC aligns to Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI).

According to CMS, NCCI was developed to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. CMS is the owner of the NCCI and is responsible for the content decisions. CCI includes code pairs which are not addressed in any other reimbursement policies as well as appropriate modifier overrides.

The National Correct Coding Initiative Policy Manual (NCCIPM) is broken into 13 narrative chapters that offer guidance on correct coding practices.

Column 1/Column 2 code edits is an edit table of procedure codes listed in two columns, with the Column 1 (comprehensive) code eligible for reimbursement; and the Column 2 (component) code not reimbursed when filed on the same date of service by the same provider or group practice.

Mutually exclusive code edits is an edit table of procedure codes listed in two columns representing procedures which cannot reasonably be performed at the same anatomic site or same patient encounter, based either on the code descriptors or the medical impossibility/ improbability that the two procedures could be performed at the same patient encounter.

Claims may be processed according to same provider or same group practice. Same group practice is defined as a physician and/or other qualified health care professional of the same specialty with the same Federal Tax ID number.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse correct coding initiatives according to the criteria outlined in this policy.

Reimbursement Guidelines

According to CMS NCCI edits, providers must report services correctly with Current Procedural Terminology (CPT^®) or Healthcare Common Procedure Coding System (HCPCS) codes that specify the most comprehensive description performed.

Blue Cross NC has adopted CMS Correct Coding Initiative (CCI) edits which promote consistent and correct coding methodologies. Like CMS, column 2 codes will not be reimbursed when filed on the same date of service with a column 1 code by the same provider or same group practice.

Each CMS CCI edit has a modifier indicator assigned to it; "0" indicating a modifier cannot be used to bypass the edit, while "1" indicates an appropriate modifier may be allowed to append the code pair and bypass the edit. However, where documentation does not support the use of the modifier on the pair, the edit will be enforced and column 2 code of the pair will not be reimbursed.

CCI indicates procedures that are considered mutually exclusive of one another. CCI Mutually Exclusive Edits are defined as codes that cannot reasonably be performed in the same session by the same provider or same group practice on the same date of service. Column 2 procedure codes will not be reimbursed when reported with an associated Mutually Exclusive column 1 procedure code.

Blue Cross NC has adapted CCI policy manual language into claims editing.

Rationale

Blue Cross NC, similar to CMS, will limit reimbursement related to NCCI editing initiatives.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com .

Related policy

Bundling Guidelines

Modifier Guidelines

References

Centers for Medicare and Medicaid Services (CMS)

National Correct Coding Initiative Policy Manual for Medicare Services

Healthcare Common Procedure Coding System

American Medical Association CPT^® Manual

History

6/1/2022 New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

12/31/2022 Routine policy review. Minor revisions only. (ckb)

11/1/2024 Clarification to the definition of same group practice. No change to policy intent. (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.