CMS developed the NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payments. CMS developed its coding policies based on coding conventions defined in the AMA CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.
The NCCI program has three types of edits: Procedure to procedure (PTP), Medically unlikely edits (MUEs) and Add-on-codes (AOCs).
The PTP edits are automated prepayment edits that prevent improper payment when you report certain codes together on the same date of service for the same patient and provider.
The PTP edits contain two categories of edits:
Hospital PTP edits which apply to Types of Bills (TOBs) subject to the Outpatient Code Editor (OCE) for the Outpatient Prospective Payment System (OPPS). These edits apply to outpatient hospital services and other facility services, including therapy providers in Part B Skilled Nursing Facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech language pathology providers (OPTs), and certain claims for home health agencies (HHAs) billing under TOBs 22X, 23X, 75X, 74X, 34X.
In some cases, a modifier may be reported, and the code pair will bypass the NCCI editing. CMS identifies which code pairs will allow bypass of the editing. The patient’s medical record must reflect that the modifier used, appropriately describes separate services. For a list of modifiers, please visit the claims center of our website.
The NCCI policy manual for Medicare services may be obtained through the CMS website. The CMS website also contains a listing of the NCCI edits which is available free to the public.
CMS developed MUEs to reduce the paid claims error rate. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE.
Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS contractors' use only. CMS does not publish the latter group of MUE values.
If you report a code with units greater than the MUE value assigned, the line and/or claim will deny.
MUE values are not utilization guidelines. They do not represent units of service reported without concern about medical review. Continue to report services that are medically reasonable and necessary.
Please visit the CMS medically unlikely edits page to search for MUEs that affect your claims.
An AOC is a HCPCS/CPT code that describes a service that, with rare exception, a practitioner does in conjunction with another primary service. An AOC is rarely eligible for payment if it’s the only procedure you report.
There are three categories of AOC files, Type 1, Type 2 and Type 3.
Please visit the CMS AOC page for additional information.
If you have questions or comments about the NCCI program you may submit inquiries related to NCCI (PTP, MUE and AOCs) edits in writing via email to ncciptpmue@cms.hhs.gov
Questions cannot be answered outside the scope of NCCI or about other CMS programs. For example, questions about modifiers not associated with NCCI, LCDs, changes to code descriptors or status indicators should be directed to the local MACs.
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