What do you do when an insurance payer denies a claim for NCCI edits, but it is contrary to the NCCI edits found on CMS’s website? Whose edit guidelines take precedence?
When you are looking at NCCI verses a local coverage determination, the local coverage determination trumps the NCCI. One of the reasons for this is because Medicare identifies scopes of practice based on what the state policies are and the state licensers. Your providers are licensed through the state and the state identifies what their scope of coverage is within that state. So the local coverage determinations are going to trump NCCI edits when it comes to Medicare patients.
Check out the Medicare Claims Denied For NCCI Edits Pop Video at https://youtu.be/LBPFjUyd8Qo