CMS uses claims coding edits to prevent overpayment or inappropriate reimbursement of Part B fee schedule services. For the physician fee schedule, there are two basic types of code edits: the Correct Coding Initiative (CCI) and the Medically Unlikely Edits (MUEs).

What is an edit in medical coding?

According to Healthcare Innovation, healthcare claims editing is a step in the claims payment cycle that involves verifying that physician-submitted bills are coded correctly.

What are the two major types of coding edits?

There are two basic types of code edits: the Correct Coding Initiative (CCI), and the Medically Unlikely Edits (MUE). Each performs a different function.

What is a code pair edit?

CMS Resources



NCCI Procedure-to-Procedure code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services.

What does a CCI edit mean?

CCI Edits. The NCCI is an automated edit system to control specific Current Procedural Terminology (CPT® American Medical Association) code pairs that can or cannot be billed by an individual provider on the same day for the same patient (commonly known as CCI edits).

What is procedure code 00000?

Anesthesia Services. CPT Codes 00000-09999. Correspondence Language Policy/Example Number 1.00000 – Standard. preparation/monitoring services for anesthesia.

How do you use correct code?

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Quote from video: It's developed and maintained by cms the centers for medicare and medicaid services and it actually has three parts the first is the procedure to procedure edit.

What are billing edits?

Billing edits are maintained within the organization’s billing system and are applied prior to the claim being staged to the bill scrubber. Bill scrubber edits. A bill scrubber is an application that performs automated claims editing to ensure the claim is appropriate and accurate for submission.

What is PTP coding edits?

Since 1996 the Medicare NCCI procedure to procedure (PTP) edits have been assigned to either the Column One/Column Two Correct Coding edit file or the Mutually Exclusive edit file based on the criterion for each edit.

What is the difference between NCCI and CCI edits?

NCCI edits are based on coding guidelines, conventions and practices and are designed to prevent improper coding and payment. CCI edits originally applied only to physician billing, but there are now tables for physicians and a subset of edits for hospital providers.

What is a procedure-to-procedure edit?

NCCI Procedure-to-Procedure (PTP) code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services. In addition to PTP code pair edits, the NCCI includes a set of edits known as Medically Unlikely Edits (MUEs).

What is CCI in medical coding?

CCI means “Correct Coding Initiative” and they are contained in the CCI Edits Handbook. You can find it online via an excel format on the CMS website or you can subscribe to the written texts that are for sale. Basically there are 2 colums which contain cpt codes.

What does Mue edit of 2 mean?

The MUE files on the CMS NCCI website display an MAI for each HCPCS/CPT code. An MAI of “1” indicates that the edit is a claim line edit. An MAI of “2” or “3” indicates that the edit is a date of service MUE.

What does Medically Unlikely Edit 0 mean?

If the MUE value is listed as 0 (zero), the HCPCS Level II/CPT® code is invalid, not covered, bundled, not separately payable, statutorily excluded, or not reasonable and necessary in accordance with Medicare regulations or guidance.

How do I read Mue edits?

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Quote from video: An mai of 2 or 3 indicates that the edit is a date of service mue mais of 2 are absolute date of service edits.

What are Mai edits?

An MUE Adjudication Indicator (MAI) of “1” indicates that the edit is a claim line MUE. a. Appropriate use of NCCI modifiers (e.g., 59, 76, 77, 91, anatomic) may be used to report the same HCPCS/CPT code on separate lines of a claim.

What is a MUE denial?

An MUE-associated denial is a coding denial, not a medical necessity denial; therefore, the provider can- not use an Advance Beneficiary Notice to transfer liability for claim payment to the patient. MUE Adjudication Indicators.

What is an MUE quizlet?

MUE (Medically Unlikely Edits) Indicators are used to determine if modifiers are allowed or not allowed to bypass an edit.

How do I appeal MUE denial?

If the units exceed the allowed MUE, the lines will be denied. An appeal should be filed with the appropriate documents to support the units billed. The patients record must clearly indicate the number of units administered and amount discarded.

What does it mean when a charge is denied for exceeding MUE?

Medically Unlikely Edit (MUE) – Number of Days or Units of Service Exceeds Acceptable Maximum. Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.

What is an MUE adjudication indicator?

MUE Adjudication Indicator (MAI): Describes the type of. MAI 1: Applied at line level (claim line) – Appropriate use of modifiers to report the same code on separate lines of a claim will enable the reporting of medically necessary units of service in excess of MUE.

What situation is modifier 59 most commonly used for?

Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

What does a 25 modifier mean?

significant, separately identifiable evaluation and management

Modifier 25 is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.

When should a 25 modifier be used?

The Current Procedural Terminology (CPT) definition of Modifier 25 is as follows: Modifier 25 – this Modifier is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional.