NCCI edits – physicians and hospital outpatient providers

The following NCCI edits are industry standard clinical coding edits that Blue Shield of California follows in accordance with your agreement:

• Procedure to Procedure (PTP) code pair edits: National Correct Coding Initiative (NCCI) (also known as CCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. NCCI Procedure-to-Procedure (PTP) code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for covered services.
   
• Medically Unlikely Edits (MUEs): An MUE is a maximum number of Units of Service (UOS) allowable under most circumstances for a single Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed by a provider on a date of service for a single member. For additional frequency editing rules and Blue Shield customizations to MUE editing, please refer to the Frequency Payment Policy.
   
• Blue Shield follows NCCI modifier guidelines when applying NCCI editing, including bypass of the edit when appropriate modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass a PTP code pair edit if the clinical circumstances do not justify its use.  
  

The PTP code pair edits, MUE tables, and NCCI manual can be accessed through the National Correct Coding Initiative Edits webpage.