The Correct Coding Initiative (CCI) was developed to control improper coding which leads to an inappropriate increase of payment in Part B claims. To encourage correct coding, policies were developed by the National Correct Coding Council based on coding conventions defined in CPT, national and local policies and edits, coding guidelines developed by national societies, the analysis of standard medical and surgical practice and the review of current coding practices.
Computerized edits were already included within the claims processing system of most Medicare carriers. Many of these edits were designed to detect “fragmentation,” or separate coding of the component parts of a procedure, instead of reporting a single code, which includes the entire procedure. However, there had not been consistency or uniformity among the carriers in correct coding edits due to:
- The direction of carrier efforts because of individual carrier discretion and established priorities
- Identification of component parts of a comprehensive procedure because of data availability and analysis expertise.
CCI edits help identify inappropriate unbundling of comprehensive procedure codes into component parts.
Unbundling is the billing of separate codes for related services when one code includes all related services. The unbundling of procedures will occur at times from a misunderstanding of coding guidelines and instructions. Unfortunately, sometimes the unbundling of procedures are inappropriately utilized to manipulate codes in order to maximize payment.
The utilization of CCI edits with the Hospital Outpatient Prospective Payment System ensures that the most comprehensive groups of codes are billed rather than the component parts. These edits also check for mutually exclusive code pairs.
FOR EXAMPLE: CPT codes 33820 and 33822 describe two types of repairs of the patent ductus arteriosus. Because only one type of repair would be performed at any given time in the same session, these procedures are considered mutually exclusive and would not be reported together.
CCI edits also include a Correct Coding Modifier (CCM) indicator, which determines whether a CCM causes the code pair to bypass the edit.
FOR EXAMPLE: Multiple services provided to a patient on one day by the same provider may appear to be incorrectly coded, when in fact the services may have been performed as reported. Because you cannot easily identify these circumstances, a modifier was established to permit claims of such nature to bypass correct coding edits.
Hospitals should ensure that they are using the CCI edits applicable to hospitals rather than the physician version. There are minor differences between the hospital and physician edits. The hospital’s version is included in the Outpatient Code Editor (OCE) which also assigns the APC. HCFA plans on issuing a new version every three months.
What is the current version? When filing claims in 2001 from:
January 1 to March 31—- use version 2.01
April 1 to June 30—- use version 2.10
July 1 to September 30—- use version 2.2
October 1 to December 31—- use version 2.3
While the HIM department may well be aware of the CCI edits, it’s important to ensure that the chargemaster has been properly reviewed to reflect the correct charges associated with the HCPCS codes. If the CCI edits identify a code pair considered to be mutually exclusive, it is inappropriate to report the two codes and their associated charges. The more inclusive procedure code should be associated with the charges for the entire procedure.
The CCI edits may be purchased through the National Technical Information Service (NTIS) Department of Commerce. HCFA has designated NTIS as the sole distributor of the CCI edits. For additional information regarding the purchase of the CCI edits, call (703) 605-6060 or (800) 363-2068. ♦