Enhanced outpatient facility editing for National Correct Coding Initiative

Beginning with claims processed on and after May 15, 2023, we will update our claims editing process for outpatient facility claims by applying the Outpatient Code Editor National Correct Coding Initiative (NCCI). NCCI edits are 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 deny 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, please visit CMS.gov and select the PTP Coding Edit page.

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