California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.12.13 - Correct Coding Initiative

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The National Correct Coding Initiative
					 Edits ("NCCI") adopted by the CMS shall apply to payments for medical services
					 under the Physician Fee Schedule. Except where payment ground rules differ from
					 the Medicare ground rules, claims administrators shall apply the NCCI physician
					 coding edits (Practitioner PTP Edits and Medically Unlikely Edits, excluding
					 codes with an MUE value of zero) to bills to determine appropriate payment.
					 Claims Administrators shall utilize the National Correct Coding Initiative
					 Coding Policy Manual for Medicare Services. If a billing is reduced or denied
					 reimbursement because of application of the NCCI, the claims administrator must
					 notify the physician or qualified non-physician practitioner of the basis for
					 the denial, including the fact that the determination was made in accordance
					 with the NCCI.
(b) The National
					 Correct Coding Initiative Coding Policy Manual may be obtained from the CMS
					 website:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/
.
					 See section
					 9789.19 for the adopted version of
					 the NCCI Coding Policy Manual, by date of service.
(c) Medically Unlikely Edits are published by
					 CMS on its website at:
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html
in the document "Practitioner Services MUE Table." See section
					 9789.19 for the adopted version of
					 the Practitioner Services MUE Table, by date of service. For services on or
					 after July 1, 2018, see section
					 9789.19 for the excerpt of the
					 adopted Practitioner Services MUE Table (which excludes codes with zero value),
					 by date of service.
(d) Physician
					 NCCI Edits are published by CMS on its website at:
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html
in the documents "Practitioner PTP Edits." See section
					 9789.19 for the adopted version of
					 the Practitioner PTP Edits, by date of service.
1. New
						section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and
						print only pursuant to Government Code section
						11340.9(g)
						(Register 2013, No. 39).
2. Amendment of subsection (b) filed
						3-23-2016; operative 1-1-2016 pursuant to Labor Code section
						5307.1(g)(2).
						Submitted to OAL for filing and printing only pursuant to Labor Code section
						5307.1(g)(2)
						(Register 2016, No. 13).
3. Amendment filed 11-6-2018; operative
						1-1-2019. Submitted to OAL for filing and printing only pursuant to Government
						Code section
						11340.9(g)
						(Register 2018, No. 45).
Note: Authority: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  5307.1 and
						  5307.11, Labor
						  Code.