The Centers for Medicare and Medicaid Services (CMS) developed the NCCI edits to promote national correct coding methodologies. The purpose of NCCI edits is to prevent improper payment when incorrect code combinations are reported. This editing applies to services provided to the same beneficiary, on the same date of service, by the same provider. Reporting both codes will generally result in the denial of payment for one of the services. However, certain code combinations are deemed allowable if the appropriate modifier is reported. In such cases, 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.
All institutional outpatient claims, regardless of facility type, process through the Integrated Outpatient Code Editor (IOCE); which includes various editing such as NCCI editing. CMS publishes a listing of codes, which are updated on a quarterly basis, on their website documenting the prohibited/acceptable code combination pairs. Each quarterly revision contains tables to identify which edits apply to OPPS claims and to non-OPPS claims.
Based on the implementation of the IOCE specifications from Change Request (CR) 10699, for claims received on or after July 1, 2018, regardless of the date of service, the following provider types that previously were not subject to NCCI edits '20' (W7020) and '40' (W7040) are now subject to these edits:
Community Mental Health Centers (CMHCs)
Critical Access Hospitals (CAHs)
Indian Health Service hospitals
End Stage Renal Disease (ESRD) facilities
Maryland (MD) Waiver hospitals
Description of the edits:
W7020 - Code 2 of a pair that is not allowed by NCCI even if appropriate modifier is present
W7040 - Code 2 of a code pair that would be allowed by NCCI if appropriate modifier is present
Review the most current quarterly release file located on CMS' website for detailed OPPS claims and non-OPPS claims updates. CMS released a Special Edition Article SE18012 on September 4, 2018, which provides a reminder on billing requirements implemented for non-OPPS providers.
CMS has implemented a six-month extension to the moratorium for MD Waiver hospitals effective October 1, 2018, through June 30, 2019, to allow additional time to adjust to the implementation of the W7020 and W7040 editing. This is an extension of the previous 90-day moratorium from October 1, 2018, through December 31, 2018. This also applies to any claims being resubmitted or appealed that were initially billed and processed from July 1, 2018, through September 30, 2018. MD Waiver providers should prepare as necessary and be ready for the W7020 and W7040 editing to reactivate for claims received on or after July 1, 2019. It is recommended to begin submitting necessary coding for NCCI as soon as possible to prevent any future impacts to claims processed during the moratorium.
Effective July 1, 2018, appeal decisions at all levels (Redetermination, Reconsideration, and Administrative Law Judge (ALJ)) resulting in a claim adjustment will now be subject to NCCI editing. The impact to providers affected by this change in editing may result in an unprocessed claim adjustment, which will Return to Provider (RTP) for correction. Since this claim adjustment was adjudicated due to an appeal decision, the provider will need to make the necessary changes to address the NCCI editing to the RTP claim as appropriate by using the claims correction process outlined in the Fiscal Intermediary Standard System (FISS) Manual Chapter 4.2 Claims Correction (21, 23, 25) for payment consideration.
NOTE: Do not resubmit these claim corrections as a new claim, corrections/changes must be made to the RTP claim. Assistance with resolving RTP claims is available through our Customer Contact Center (JH) (JL)