Update — Enhanced outpatient facility editing for National Correct Coding Initiative

In the April 2023 edition of Provider News, it was announced that for claims processed on and after May 15, 2023, we would update our claims editing process for outpatient facility claims by applying the outpatient code editor National Correct Coding Initiative (NCCI). This update was delayed and as a result, the NCCI edits will be applied to claims processed on and after October 1, 2023.

As a reminder, NCCI edits are Centers for Medicaid & Medicare Services (CMS) developed guidelines to promote national correct coding based on industry standards for current coding practices. These edits provide an opportunity to shift certain existing back-end reviews to front-end adjudication for outpatient facility claims. While this may facilitate quicker claim adjudication, it may also cause claims to be denied if correct coding guidelines are not followed. This includes, but is not limited to, scenarios with procedure-to-procedure editing (for example, mutually exclusive or the procedure is a component of another procedure). For additional information, visit CMS.gov.

If you have questions about this communication or need assistance with any other item, contact your Provider Relationship Management representative.