Next question, what are CCI edits. I hear you mention CCI edits quite a bit, can you give me a brief overview explanation of what CCI edits are and how I can access them. So, I have a nice answer for you for that one. I didn’t realize I talked about CCI edits that much but it is good to know. Just so that everyone knows and doesn’t panic, you are not tested on the two Board exams about CCI edits. Its just something that’s good to know to be a well rounded coder. So, first of all it stands for National Correct Coding Initiative or CCI for short. Technically, it should be NCCI but everyone says CCI. These are for your CPT and HCPCS Code for physician in out-patient hospital settings. They are going to affect reimbursement so they are important to understand, not that all coders do billing but coding obviously is done for reimbursement privileges so we should understand this information.
Why CCI Edits Were Created- Video
So why were these CCI edits created? To prevent unbundling of services, for example, my famous example that I always use, an exploratory laparotomy, where they use an incision, laparo means abdomen so they are cutting into the abdomen maybe to look around and see what’s wrong to diagnose something but they are not really fixing anything, they are not doing any surgery so if you bill a 49000 with another procedure like an oophorectomy, removal of ovaries, that 49000 is bundled into the oophorectomy because you have to do a laparotomy to go take the ovaries out. So these edits would show you that those two codes together….can’t work it hits an edit so that’s an unbundling. The second bullet prevents incorrect payments from being made due to inappropriate CPT and HCPCS code usage. Detect incorrect or inappropriate reporting of combinations of codes and curtail improper coding practices that lead to increased payment. So it’s a system of checks. You know about diagnosis to procedure code edit so you could have a very expensive procedure but if you don’t have a good diagnosis to support it, they are going to deny it. That’s an edit. This is just a different type of edit. Instead of CPT and ICD, these two CPT codes cannot go together. These edits are performed on every possible pairing of CPT and HCPCS. Remember when we say HCPCS coding system it includes CPT, CPT is level 1 of HCPCS as coders, when we think of HCPCS, we think of the volume II book but it actually is both. They were developed and continue to be enhanced using coding conventions defined in the AMA CPT manuals with national and local policies and edits, national societies help develop coding guidelines and now its just a standard medical and surgical practice and review of current coding factors.
So what does it look like? Basically you are going to have, well it started off as two tables, CPT and HCPCS codes. The table would have column 1 and a column 2. Column 1 is considered the correct code or the allowable code. Column 2 is considered the wrong code in relation to the one column 1, my examples oophorectomy in column 1 and laparotomy in column 2. They would papy for the oophorectomy but they would kick out the laparotomy. So the claim hits an edit, Medicare will pay the column 1 code but not the column 2 code. There are two types of tables, one is the comprehensive/component edit which is what that oophorectomy example is and it contains codes that should not be billed together. The other is called mutually exclusive procedure and has procedures that can’t reasonably be done together. For example: often times we will have a procedure and it will say “partial” and then indented underneath it it will say complete or vice versa. But you would never bill those two codes at the same time. It was either partial or complete. So hopefully you can kind of get an idea of the two types. According to the CMS website, these two tables have now been combined into one. Let me take you there so you can see this. I just Googled “CMS CCI edit” help me find the page I need, so its home medicare national correct coding. So it gives you all the history, a lot of the things that I just said, it’s a very good read, its got these downloads here and this one is very good – “how to use the national correct coding initiative” – this is from the medicare learning network. It has screen shots and it tells you exactly what they are, why we need to use them, how to use them how to locate them so this is definitely a great primmer to print off read and study.
On the CMS website, they have it, its free, it used to be you had to pay for this but its kind of awkward to use. I like using in coders like find a code and they have under more and findacode.com is an online coder that I really like I think because its purple, its my favorite color but I will show you a way to get this edit at a discount if you are interested. Let me click on the more link, it’s a MCCI edit and here its got MCCI edit guide and manuals, this is really great it has all the information at your fingertip in this one little utility along with all of your ICD and CPT codes and all of that good stuff. If you want to actually use it, down here in the lower right hand corner, scrubbing and validation, MCCI edit validator and you can do it for nonfacility or facility so if we did it for nonfacility this is what the screen looks like and I was in here earlier to answer another question and I just popped the two codes in and it lets me know that no, they don’t hit a MCI edit, one is not bundled into the other. So coders make it very easy.
2 thoughts on “What Are CCI Edits?”
We are an ASC that specializes in retina surgeries, how or where would I look to find out what, if any, G codes are needed for a procedure? For example 65930, does that need to be billed with a G code? If so which ones?
Hi Laticia – that is a great question to be covered in one of our venues at http://cco.us/topic-request then you’ll get your answer and we’ll most likely put it on the blog here later. –Laureen