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.

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.

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, Same Individual Physician or Other Health Care Professional 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.

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 for Medicare 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 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.

Receipt of code pairs on different claims or out of order may lead to reimbursement of column 2 codes instead of column 1, such as when column 2 codes are submitted and reimbursed on an initial claim, with a subsequent claim being submitted for the column 1 code.

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

Rationale

Blue Cross NC follows CMS guidance on 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. (cjw)

Application

These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.

This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) 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.