Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director - Administrative Rules
Article 5.3. Official Medical Fee Schedule
(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.
Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.
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).