Question

Prior to submitting claims forms to insurance payers, claims are generally scrubbed to identify and resolve payer specific edits. Some of the most common edits include the National Correct Coding Initiative (NCCI), Outpatient Code Edits (OCE) and Medicare Code Edits (MCE).

Note: The Medicare Code Edits (MCE) link above will take you to the CMS.gov website. To access the CMS MCE Manual:

Go to CMS Acute Inpatient Prospective Payment System (IPPS) This link will take you to an external website

In left hand navigation menu, select desired year for "FY IPPS Final Rule Home Page" They are by year

In table, select desired year for "FY Final Rule and Correction Notice Data Files"

Scroll to "Downloads" section

Select "Definition of Medicare Code Edits v33" zip file

Select/open "ICD-10 Definitions of Medicare Code Edits_v33.0.pdf"

Assignment

In this application assignment, you will explore the Centers for Medicare and Medicaid Services (CMS), NCCI, OCE and MCE edits to respond to the following questions:

1. What are NCCI edits? How are NCCI edits used during the claims scrubbing process?

2. What are OCE edits? How are OCE edits used during the claims scrubbing process?

3. What are MCE edits? How are MCE edits used during the claims scrubbing process?

4. Define the term unbundling and provide an example.

5. What are the benefits of resolving claims edits prior to submission?

Answer 1

ANSWERS :

1. NCCI EDITS : National correct coding initiative is one of the CMS program which is designed to prevent submission of improper payments of the procedures which should not be submitted if they are wrong. In the NCCI edits two categories are present they are - code pair edits and physician edits. NCCI edits are used during the claims of scrubbing process using a set up of PTP edits which enters automatically into code editors of outpatient services.

2. OCE EDITS : Outpatient code editor (OCE) is a system editing process which is created and used by CMS to facilitate the claim process of outpatients, and to identify inappropriate and wrong coding of these claims. This program check out the errors and give back edit flags, gives an APC number for each claim and service which covers under OPPS provides information which is kept in price program, assign ASC payment group in performing of services.