2021 Evaluation & Management Changes
Significant changes were made to the office and outpatient Evaluation and Management services in 2021. Read more about the updates in 2021 Coding Updates and Changes: CPT®, HCPCS, and ICD-10 CM and on the Coding and Reimbursement page.
Coding Edits
The National Correct Coding Initiative (NCCI) edits are developed by CMS to establish a uniform coding review method among MACs (Medicare Administrative Contractors). NCCI edits help the agency promote correct coding, enforce Medicare payment policies, and control improper payments made by inappropriate coding. The Centers for Medicare and Medicaid Services publishes updates to the NCCI edits for Procedure to Procedure and Medically Unlikely Edits on a quarterly basis. The organization also publishes the NCCI policy manual on an annual basis.
MLN Booklet: “How to Use the Medicare National Correct Coding Initiative (NCCI) Tools”
Medicare Contractors
Targeted Probe and Educate Program (TPE)
Medicare Parts A & B Appeals Process
RAC Program Information and Resources
The Recover Audit Contractors (RAC) initiative was developed by the Centers for Medicare and Medicaid Services (CMS) to fight fraud and abuse in the Medicare program.
Skilled Nursing Facility (SNF) Consolidated Billing
SNF Consolidated Billing resource
Resource: CMS’ Overview of SNF billing
National Coverage Determinations, Local Coverage Determinations, and Coding/Reporting Information
- National coverage determination (NCD): a general outline of coverage which is applicable regardless to which Medicare Administrative Contractor (MAC) is administering claims for a region.
- Local coverage determination (LCD): specific to a MAC.
- National Coverage Analysis (NCA): a document published in response to a review request.
- Local Coverage Articles (LCA): can act as companion pieces to local coverage determinations or stand alone to communication information about an item/service.
Search for policies with CMS MCD Search tool:
Refer to Medicare Coverage Determination Resource for more information regarding coverage determinations and the development process.
CMS Medicare Manuals
CMS’ internet-only manuals provide detailed information on Medicare eligibility, provider participation, benefits, coverage, claims processing and more.
Medicare Benefit Policy Manual
Medicare Claims Processing Manual
Medicare National Coverage Determinations Manual