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Shane Posted Fri 02nd of August, 2013 22:42:12 PM

We are debating whether are not inactively-enforced CCI Edit
conflicts are used by private health insurance companies. We have received feedback that while a conflict may not be enforced according to CMS, that a commercial carrier may still enforce a conflict. True or false? Any other info regarding CCI's would be appreciated.

SuperCoder Answered Mon 05th of August, 2013 04:56:41 AM


I have forwarded this to my senior colleagues to give you a complete definitive answer.


SuperCoder Answered Mon 05th of August, 2013 07:35:12 AM

CCI or NCCI (National Correct Coding Initiative) is an initiative taken by CMS. The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.

Therefore, CCI/NCCI is a Medicare thing. Medicare MACs and Payers that follow Medicare rules obey the CCI edits for compliance purpose. However Commercial payers can have their own sets of cpmpliance policies including bundling edits. Some commercial carriers do follow Medicare rules, so hey follow Medicare CCI. Others may not follow CCI edits. Private insurances/commercial payers create and implement their own sets of rules for bundling. So two codes that are bundled with each other under CCI, might not be bundled at all under a commercial payer's policy.

McKesson has its own bunch of edits including bundling, known as "Black box edits". AAOS publishes GSD (Global Service Data) manual which does not follow all CCI edits. There are many more such examples.

To read more about CCI, please visit the below CMS page:

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