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Mutually and Non-Mutually Exclusive NCCI Supplemental Edits

Reimbursement Policy:
Mutually and Non-Mutually Exclusive NCCI Supplemental Edits

Effective Date:
02/25/2019

Purpose:
Provide guidelines for the application of supplemental edits that are not addressed by CMS within their mutually and non-mutually exclusive edits. Horizon BCBSNJ 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:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included. ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

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 BCBSNJ 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 BCBSNJ has adopted edits to deny 97014 when submitted with G0151.

Procedure:
In accordance with NCCI guidelines, Horizon BCBSNJ 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.

No additional reimbursement shall be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply. Providers may not bill for the difference due to reduced payment.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

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

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
11/26/2018: Policy approved

Policy124_V1.0_11262018