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Locate guidelines on the CMS website
Last Modified: 5/3/2024
Location: FL, PR, USVI
Business: Part A, Part B
A procedure can have other policies or guidelines besides an LCD or NCD. The CMS website has a wealth of information.
These articles explain Medicare policy in an easy-to-understand format. They focus on coverage, billing, and payment rules for specific provider types. They are prepared with assistance from clinicians, billing experts and CMS subject matter experts.
CMS developed NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payments. NCCI procedure-to-procedure code pair edits apply to services provided on the same date of service by the same physician. Reporting both codes will generally result in the denial of payment for one of the services.
The purpose of the NCCI procedure-to-procedure (PTP) edits is to prevent improper payment when incorrect code combinations are reported. NCCI contains a:
• table of edits for physicians/practitioners
• table for outpatient hospital services.
Under the Related Downloads, NCCI contains one PTP table of edits for physicians/practitioners and one PTP table for outpatient hospital services. NCCI files are updated quarterly. Select on the one that represents your item or service.
Once the proper PTP edit code range is selected, another window will open with viewing options. The most efficient way to filter is to use excel. Locate the file you want to view and download.
To search for a specific code combination, first click on data, then select the column you would like to search. Select control +F on your keyboard and enter the specific procedure code. This will allow you to review all code combination for that specific procedure code entered.
• A is the primary payable code
• B contains the secondary code which may not be payable (append modifier if applicable)
• C is the edit status before 1996
• D is the effective date of the edit
• E is the deletion date of the edit
• F indicates if a modifier is permitted
• G provides the category for the rationale of each PTP edit
A MUE is a maximum number of units of service allowable under most circumstances for a single CPT/HCPCS code billed by a provider on a single date of service for a single patient. MUEs were developed to reduce the paid claims error rates based on anatomical consideration, CPT instructions, CMS policies and clinical judgment. MUEs are updated quarterly.
Navigate to the MUE edits from the left navigation bar on the NCCI page of the CMS website.
There are three types of MUE edit files listed above under related downloads:
• supplier services
• outpatient hospital services
• services
Select the appropriate file.
The MUE table will open in another window.
• A contains the CPT/HCPCS codes.
• B is the MUE value representing the maximum units of service.
• C is the MUE Adjudication Indicator (MAI).
• 1 is a line level edit which means you can bill up to the MUE per line of service.
• May require modifiers to distinguish.
• 2 is an absolute date of service edit which means CMS gives no instances in which a higher value would be correct and payable. Appeals will not be overturned even with documentation.
• 3 is a date of service edit which means it can be appealed with additional documentation of medical necessity to support reported units.
• D is the MUE rationale.
If you do not find what you are looking for, an item or service may have coverage under the First Coast LCDs.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
