Mutually and Non-Mutually Exclusive NCCI Edits

Effective Date: October 14, 2019

Purpose:
Provide guidelines for the application of supplemental edits that are not addressed by CMS within their mutually and non-mutually exclusive edits. Horizon NJ Health will apply similar logic to codes that CMS does not recognize, but should be treated in a similar fashion as the codes that CMS does recognize. This policy shall apply to professional providers.

Scope:
Products included:

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

Policy:
Currently, some CPT and HCPCS codes are not addressed in the National Correct Coding Initiative (NCCI). This is primarily due to the fact that CMS either does not recognize the CPT or HCPCS code or because the service is excluded from the Medicare program. In some cases, CMS instructs providers to utilize a different code in place of a code not recognized by CMS. Horizon NJ Health will implement supplemental edits for the 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, but 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:
In accordance with NCCI guidelines, Horizon NJ Health shall deny CPT and HCPCS 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:
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
cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

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