CODING AND REIMBURSEMENT | The Medicare National Correct-Coding Initiative: A Tutorial

By Anna Marie Jilla

This article is a part of the March/April 2022, Volume 34, Number 2, Audiology Today issue. 

The purpose of this article is to review the Center for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) as it relates to audiology coding and reporting for Medicare Part B claims, specifically for Procedure-to-Procedure (PTP) code-pair edits. 

NCCI edits are updated quarterly by the CMS; therefore, information in this article may have changed since the article was submitted for publication. It is recommended that clinicians reference primary sources of information (i.e., the CMS website) whenever possible.

Background on the National Correct Coding Initiative (NCCI)

Medicare, a federally funded health-care program in the United States, is the largest single insurer of Americans. Payments for claims made under the Medicare program are carefully monitored, as ineffective operations can be costly to the solvency of the program and the federal budget. 

Managing claims payments is one way of controlling the Medicare budget and the NCCI was developed by the CMS “to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment of [Medicare] Part B claims” (CMS NCCI: Policy Manual for Medicare, Introduction, p. 3) (CMS, 2022).

Correct coding policies are conventions developed by the CMS to reduce unnecessary spending under the traditional Medicare program (i.e., Medicare Parts A and B). Rules take into account the codes available through the American Medical Association (AMA) Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS), national and local Medicare policies, standards of clinical practice, coding guidance from national societies, and current coding practice (CMS NCCI: Policy Manual for Medicare, Introduction, p. 3) (CMS, 2022).

The NCCI promotes several generic, correct coding conventions including:

• The accurate reporting of services performed.
• Avoiding unbundled reporting of codes where a comprehensive CPT or HCPCS code more accurately describes the service or fragmenting the reporting of a procedure into its component parts (e.g., reporting component services of 92557-Comprehensive audiometry threshold evaluation and speech recognition).
• Avoiding unbundled reporting of a bilateral procedure into two unilateral procedures.
• Avoiding downcoding or upcoding in favor of reporting CPT or HCPCS codes that best describe the services rendered.
• The correct reporting of dates and units of service for quantity-based codes (e.g., 95992–Canalith repositioning procedure, per day only allows one unit to be reported per day, per patient, per provider).