Mutually and Non-Mutually Exclusive NCCI Edits

Effective Date: October 14, 2019
Last Updated: July 25, 2021

Purpose:
To provide guidelines for the application of supplemental edits that are not addressed by CMS within their mutually and non-mutually exclusive edits. This policy applies to both professional providers and outpatient facilities.

Scope:
Products included:

  • NJ FamilyCare/Medicaid Plan
  • Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Policy:
Horizon NJ Health utilizes supplemental edits for codes that are not addressed by CMS, which should be treated in a similar fashion to the NCCI and NCCI mutually exclusive edits associated with the codes that CMS does recognize. Such code pair combinations will be considered to be mutually exclusive and not reimbursable separately, as these are deemed to be included in the reimbursement for the other code in the pair.

As an example, CMS considers 97014 (Application of a modality to one or more areas; electrical stimulation) to be invalid for Medicare. Instead, CMS instructs providers to bill G0283 (Electrical Stimulation [unattended], to one or more areas for indication[s]) other than wound care, as part of a therapy plan of care. CMS has NCCI edits to deny G0283 when billed with G0151 (Services of physical therapist in home health setting, each 15 minutes). Since some providers will still be billing using code 97014 for claims submitted to commercial health plans, Horizon NJ Health has adopted edits to deny 97014 when submitted with G0151.

Procedure:
Horizon NJ Health will not consider for reimbursement CPT and HCPCS level II codes not recognized by CMS but should be treated in a similar manner to a CMS recognized procedure code associated with an NCCI edit.

Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Benefit Limitations;
  • The terms of any applicable provider participation agreement;
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
  • Medical necessity; and
  • Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:
CMS National Correct Coding Initiative Edits
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services

History:
Date Updates/Change

07/25/2019

Policy Approved

07/25/2021

General formatting changes. Added verbiage to include outpatient facilities in scope.