Mastering Medicare’s NCCI Edits and the Relative Value File

The National Correct Coding Initiative (NCCI) and the Relative Value File are two database files that the Center for Medicare and Medicaid Services (CMS) created for correct coding rules and guidelines related to Medicare claims. Most commercial carriers have also implemented these rules and guidelines in their claims processing in bundling services and other applications of coding medical claims for professional providers. There is a wealth of information in these files to not only apply the rules and guidelines for clean claims but to also be able to defend coding submitted when it is denied.

In this 1 hour session, we will go deep into these files, looking at what information is shared, and the utilization of these filed not only for billing and coding but for claims processing and understanding denials as the cause of many denials is that a claim does meet the requirements of the information in these files and considered a claim with an error(s).

There are several different parts of these files so it is important to understand each part it know which ones should be applied to a particular claim and if there is a need to alter a claim utilizing modifiers, codes, etc. It is sometimes difficult to know to where to turn when there is a question on how services or procedures should be coded, or what is considered bundled or unbundled. CMS publishes these edits at no charge and they are available to anyone on the cms.gov website.

• Recognize the coding edits created by the Center for Medicare and Medicaid Services (CMS)
• Understand how insurance companies use the National Correct Coding Initiative (NCCI) to process claims
• Apply the policies and guidelines in the NCCI Policy Manual for clean claims.
• Determine what you can apply to your coding and billing from the relative value file.
• Create custom files with coding information for your practice
• Defend coding by using the NCCI and Relative Value File for appeals on denied claims
• Realize the Medically Unlikely Edits(MUE) for quantity billing and know that there are 2 parts.

NCCI

• Procedure to Procedure Edits
• Medically Unlikely Edits
• Policy Manual

Relative Value File

• CPT/HCPCS Cod status
• RVU Values
• Post-operative period
• Assistant at Surgery
• Supervision for diagnostic testing
• Bilateral procedures

CMS-created files that include claims edits and other coding information to assist in proper coding for medical claims. Both the NCCI and Relative Value File give guidance for Medicare claims. Many commercial carriers also use these files to process claims also.

• Billers
• Coders
• Administrators
• Collector
• Supervisors
• Claims adjusters
• Reimbursement Specialist