NCCI edits are one component of the NCCI methodologies. The 6 Medicaid NCCI methodologies contain approximately 3 million Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs) as of March 2017. The NCCI edits are defined as edits applied to claims for services performed by the same provider, for the same beneficiary, on the same date of service. Providers report procedures / services performed on beneficiaries utilizing HCPCS / CPT codes. These codes are submitted on claim forms to fiscal agents for payment.

The NCCI methodologies contain 2 types of edits:

1. NCCI procedure-to-procedure (PTP) edits define pairs of HCPCS / CPT codes that should not be reported together for a variety of reasons. These edits consist of a Column One code and a Column Two code. If both codes are reported, the Column One code is eligible for payment and payment for the Column Two code is denied. However, each PTP edit has an assigned modifier indicator, which provides information on whether a PTP-associated modifier may be used to bypass the edit, in appropriate circumstances, and allow payment for both the Column One and Column Two codes. An indicator of "0" means that a modifier cannot be used to bypass the edit. An indicator of "1" means that a PTP associated modifier, such as 25, 59, RT, LT, etc., may be used, if appropriate, to bypass the edit. An indicator of "9" means the edit has been deleted and the modifier indicator is not relevant.
2. Medically Unlikely Edits (MUEs) define for many HCPCS / CPT codes the maximum number of units of service (UOS) that are under most circumstances billable by the same provider, for the same beneficiary, on the same date of service. Reported UOS greater than the MUE value are unlikely to be correct (e.g., a claim for excision of more than one gallbladder or more than one pancreas). Billed claim lines with a unit-of-service value greater than the established MUE value for the HCPCS / CPT code are denied payment in their entirety.

FAQ ID:95011