Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
What guidance did State Medicaid Director Letter (SMDL) #10-017 implement?
SMDL #10-017 (PDF, 133.63 KB) issued on September 1, 2010 provided guidance on the implementation of the Patient Protection and Affordable Care Act (P.L. 111-148), as amended by the Health Care and Education Recovery Act of 2010 (P.L. 111-152), together referred to as the "Affordable Care Act", which were signed into law on March 23, 2010. In this SMDL, the Centers for Medicare & Medicaid Services (CMS) provided guidance and established policy in support of implementation of section 6507, "Mandatory State Use of National Correct Coding Initiative (NCCI)", in Subtitle F, "Additional Medicaid Program Integrity Provisions", Title VI, "Transparency and Program Integrity".
What does section 6507 of the Affordable Care Act require of state Medicaid programs, with regards to the National Correct Coding Initiative (NCCI)?
Section 6507 of the Affordable Care Act requires each state Medicaid program to implement compatible methodologies of the NCCI, to promote correct coding, and to control improper coding leading to inappropriate payment. Specifically, section 6507 of the Affordable Care Act amends section 1903(r) of the Social Security Act (the Act). Section 1903(r)(4) of the Act, as amended, required that the CMS notify states by September 1, 2010, of the NCCI methodologies that are "compatible" with claims filed with Medicaid, in order to promote correct coding and to control improper coding leading to inappropriate payment of claims under Medicaid.
The CMS was also required to notify states of the NCCI methodologies that should be incorporated for claims filed with Medicaid for which no national correct coding methodology has been established for Medicare. In addition, the CMS was required to inform states on how they must incorporate these methodologies for claims filed under Medicaid.
Section 1903(r)(1)(B)(iv), as amended, also required that states incorporate by October 1, 2010, compatible methodologies of the NCCI administered by the Secretary and other such methodologies as the Secretary identifies. This means that states were required to incorporate these methodologies for Medicaid claims filed on or after October 1, 2010.
The CMS was also required to submit a report to Congress by March 1, 2011, that included the September 1, 2010 notice to states and an analysis supporting these methodologies.
What is the National Correct Coding Initiative (NCCI)?
The NCCI is a CMS program that consists of coding policies and edits. Providers report procedures / services performed on beneficiaries utilizing Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) codes. These codes are submitted on claim forms to fiscal agents for payment. NCCI policies and edits address procedures / services performed by the same provider for the same beneficiary on the same date of service.
This program was originally implemented in the Medicare program in January 1996 to ensure accurate coding and reporting of services by physicians. The coding policies of NCCI are based on coding conventions defined in the American Medical Association's Current Procedural Terminology Manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, and / or current coding practice.
With regards to the National Correct Coding Initiative (NCCI), what if a new methodology is discovered that was not identified in SMDL #10-017?
The CMS fully anticipates, and will continue to evaluate the application of, additional NCCI methodologies and / or edits that will achieve additional savings that are possible as a result of proper coding. Additional methodologies may be developed later and, if so, the CMS will update states regarding the progress of NCCI methodologies in Medicaid moving forward. An example of this are the NCCI Procedure-to-Procedure (PTP) edits for DME which were implemented in the Medicaid NCCI Program in October 2012.
What is a National Correct Coding Initiative (NCCI) edit and how does it differ from an NCCI methodology?
NCCI edits are one component of the NCCI methodologies. The 6 Medicaid NCCI methodologies contain approximately 3 million Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs) as of March 2017. The NCCI edits are defined as edits applied to claims for services performed by the same provider, for the same beneficiary, on the same date of service. Providers report procedures / services performed on beneficiaries utilizing HCPCS / CPT codes. These codes are submitted on claim forms to fiscal agents for payment.
The NCCI methodologies contain 2 types of edits:
- NCCI procedure-to-procedure (PTP) edits define pairs of HCPCS / CPT codes that should not be reported together for a variety of reasons. These edits consist of a Column One code and a Column Two code. If both codes are reported, the Column One code is eligible for payment and payment for the Column Two code is denied. However, each PTP edit has an assigned modifier indicator, which provides information on whether a PTP-associated modifier may be used to bypass the edit, in appropriate circumstances, and allow payment for both the Column One and Column Two codes. An indicator of "0" means that a modifier cannot be used to bypass the edit. An indicator of "1" means that a PTP associated modifier, such as 25, 59, RT, LT, etc., may be used, if appropriate, to bypass the edit. An indicator of "9" means the edit has been deleted and the modifier indicator is not relevant.
- Medically Unlikely Edits (MUEs) define for many HCPCS / CPT codes the maximum number of units of service (UOS) that are under most circumstances billable by the same provider, for the same beneficiary, on the same date of service. Reported UOS greater than the MUE value are unlikely to be correct (e.g., a claim for excision of more than one gallbladder or more than one pancreas). Billed claim lines with a unit-of-service value greater than the established MUE value for the HCPCS / CPT code are denied payment in their entirety.
What does the CMS provide to states in order to implement National Correct Coding Initiative (NCCI) in Medicaid?
The CMS provides states the Medicaid NCCI edit files for downloading on a quarterly basis approximately 45 days before the beginning of a new calendar quarter. These files are available for downloading by states on the Medicaid Integrity Institute (MII) website on a secure portal (RISSNET). The files are available in 3 file formats: fixed-width ASCII text, tab-delimited ASCII text, and Excel 2007. The files are complete replacements of the files for the previous calendar quarters.
The following public documents are posted on the Medicaid NCCI pages:
- NCCI Edit Files. The most recent versions are posted in tab-delimited ASCII text and Excel 2007 file formats. These documents are intended for use by other interested parties (e.g., providers), not by state Medicaid agencies.
- Change Reports. These documents identify the changes to the NCCI edits from the previous quarter to the current quarter. These reports are posted in Excel 2007 and tab-delimited ASCII text formats.
- National Correct Coding Initiative Policy Manual for Medicaid Services. This manual is helpful in understanding the policies on which the Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs) are based and will assist staffs in customer service, medical review, and appeals.
- NCCI Correspondence Language Manual. This manual provides information about the Correspondence Language Example Identification Number (CLEID), which is associated with each PTP edit and MUE. The CLEID provides general information about the rationale for the edits, which can be used to help educate providers about the edits.
- Reports to Congress.
- Medicaid National Correct Coding Initiative Technical Guidance Manual. This document provides information for state Medicaid agencies and fiscal agents about NCCI policies.
What funding is available to states to implement section 6507 of the Affordable Care Act?
Section 1903(r) of the Social Security Act (the Act), as amended by section 6507 of the Affordable Care Act, describes the functionality of a state's MMIS system or a state's information retrieval and automated claims-payment processing system. With the enactment of this section, state MMISs must include Medicaid NCCI methodologies as part of their functionality. Section 1903(a)(3) of the Act provides the CMS with the authority to provide enhanced federal financial participation (FFP) to states for the design, development, installation, and maintenance of the state's MMIS. Thus, in considering revisions to a state's MMIS, the CMS is authorized to provide 90 percent FFP to states to incorporate Medicaid NCCI methodologies into the state's MMIS.
The CMS will utilize the current Advanced Planning Document (APD) process for states to request such funding for a state's MMIS. States should work with their respective CMS Regional Offices to request enhanced FFP through submission of a Medicaid NCCI APD.
With regards to National Correct Coding Initiative (NCCI), are all Medicaid Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs) published and available to states and providers on the CMS website?
All currently active and previously active Medicaid Procedure-to-Procedure (PTP) edits are published on the Medicaid.gov website for use by the general public and interested parties. Medicaid Medically Unlikely Edits (MUEs) that are active for dates of service in the current quarter are published on the Medicaid.gov website for use by the general public and interested parties; previous MUEs with deletion dates prior to the current quarter are not included.
States and providers must be aware that there are a number of differences between Medicaid and Medicare NCCI edits. For example:
- Medicare has some non-published / confidential MUEs. However, there are no confidential or non-published edits in the Medicaid NCCI program at this time.
- MUEs for the same code may have different values in the Medicare and Medicaid NCCI programs.
- The Medicaid NCCI program has PTP edits for durable medical equipment; the Medicare NCCI program does not.
- The Medicaid NCCI program has PTP edits and MUEs for codes that are not covered or not separately payable by the Medicare program.
It is important that providers and others use the correct website to obtain the Medicaid PTP edit and MUE files. Providers and others sometimes access the Medicare NCCI section of the CMS.gov website to obtain the NCCI edit files, rather than the Medicaid NCCI section of the Medicaid.gov website. It is important to note, there are 2 separate NCCI pages, 1 for each program. Conducting a general search of "NCCI" or "National Correct Coding Initiative" directly from the CMS.gov website will take the user to the Medicare page, not the Medicaid page. Providers and others should go to the Medicaid.gov website to obtain Medicaid-related NCCI information and edit files.
States must download the NCCI edit files that are available on the Medicaid Integrity Institute (MII) website using a secure portal (RISSNET) rather than using the publicly available files from the Medicaid.gov website. States must ensure that they or their vendor are using the appropriate Medicaid NCCI edits to adjudicate Medicaid claims.
If a provider receives a denial that is attributed to an NCCI Procedure-to-Procedure (PTP) edit or Medically Unlikely Edits (MUEs), can the provider verify the edit on the Medicaid NCCI webpage on the Medicaid.gov website?
As discussed above, all currently active Medicaid PTP edits and MUEs are published on the Medicaid NCCI webpage on the Medicaid.gov website - i.e., all edits that are applicable to claims with dates of service in the current calendar quarter:
- The PTP edit files that are posted on the Medicaid.gov NCCI webpage also contain historical information - i.e., they contain the effective date of every edit and the deletion date of prior edits. This information can be used to verify whether a particular PTP edit was valid on the date of service (DOS) of the claim in question and whether use of a PTP-associated modifier would allow the claim to bypass the edit.
- The MUE files on the Medicaid.gov NCCI webpage identify the edits that are applicable to claims processed in the current quarter and with dates of service in the current quarter. They do not contain historical information - i.e., they do not contain the effective dates of current edits nor do they include prior edits that have been deleted or revised. However, that information is available to the states in the files that a state downloads from the MII website using a secure portal (RISSNET). Providers who want to verify whether there was an MUE and what the value was for that MUE on a DOS prior to the current quarter would need to contact the state.
As discussed above, it is imperative that providers access the Medicaid NCCI edit files on the Medicaid NCCI webpage on the Medicaid.gov website and not the Medicare NCCI edit files, as there are significant differences between the 2 sets of files.If providers are reporting NCCI-related denials that are not appearing in the Medicaid NCCI edit files, the state should contact their vendor or check their system to determine the origin of the edit. If the edit is not part of the Medicaid NCCI PTP editor MUE file sets, the denial may not be attributed to NCCI. States have the flexibility to create other Procedure-to-Procedure edits or units-of-service edits, but should be using state-specific denial messages for these edits, not NCCI-related denial messages.
Can denials resulting from National Correct Coding Initiative (NCCI) edits be appealed?
A provider impacted by an NCCI-related claim denial shall be subject to the standard state appeals or claim resubmission process(es). States are not required to have a formal appeals process to address claim denials. However, states must ensure that providers have an adequate opportunity to alert them to potential errors associated with claim denials, including those generated by NCCI edits, and that providers have an avenue to resubmit claims or provide additional documentation to support their claims.