Alert 10003 (NCCI Edits)

Owned by Roman Konovalov
Last updated: Aug 11, 2020Version comment
2 min read

Description:

  1. This check uses NCCI Edits for generating alerts.
  2. All possible CPT codes pairs are checked. For example, if this check is run for three CPT codes 00102, 36010 and 25115, then the following combinations is checked:
    1. Code 1 = 00102 and Code 2 = 36010.
    2. Code 1 = 00102 and Code 2 = 25115.
    3. Code 1 = 36010 and Code 2 = 00102.
    4. Code 1 = 36010 and Code 2 = 25115.
    5. Code 1 = 25115 and Code 2 = 00102.
    6. Code 1 = 25115 and Code 2 = 36010.
  3. Therefore, pair "Code 1 - Code 2" is not the same as pair "Code 2 - Code 1".
  4. One error is generated for every pair with found NCCI Edit.
  5. The validation result may be an error or warning, depending on a particular NCCI Edit.
  6. The error message includes Edit Rationale if it is available in NCCI Edit.

Edit ID: 10003

Error type: ERROR or WARNING depending on a particular NCCI Edit.

Error message example:

This example is provided for the following codes:

  1. Code 1 = 00102.
  2. Code 2 = 36010.

CPT code 36010 CANNOT BE BILLED together with CPT code 00102 under any circumstance as CPT code 36010 is bundled into the service depicted by CPT code 00102. Only CPT code 00102 can be billed based on coding policies and guidelines. CPT code 36010, if billed with CPT code 00102, would be rejected by a payer.

PTP Edit Rationale: Standard preparation / monitoring services for anesthesia.

DESCRIPTION

CPT code 00102 = Anesthesia For Procedures Involving Plastic Repair Of Cleft Lip

CPT code 36010 = Introduction Of Catheter, Superior Or Inferior Vena Cava

Warning message example:

This example is provided for the following codes:

  1. Code 1 = 31375.
  2. Code 2 = 36405.

CPT code 36405 cannot be billed with CPT code 31375 in normal circumstances as CPT code 36405 is bundled into the service depicted by CPT code 31375. However, under special scenarios, if clinical documentation and medical necessity support, CPT code 36405 CAN BE billed with CPT code 31375  by appending a CCI-overriding modifier to CPT code 36405, e.g. 59, 57, 25 or cardiology modifiers. The overriding modifier would be possible to add once the Health Authority allows it.

PTP Edit Rationale: Standards of medical / surgical practice.

DESCRIPTION

CPT code 31375 = Partial Laryngectomy (Hemilaryngectomy); Laterovertical

CPT code 36405 = Venipuncture, Younger Than Age 3 Years, Necessitating The Skill Of A Physician Or Other Qualified Health Care Professional, Not To Be Used For Routine Venipuncture; Scalp Vein

Owner object: Activity

Owner object property name: Code

Owner object property value: Value of Activity.Code

Reference object: Claim

Reference object property name: ID

Reference object property value: Value of Claim.ID