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 are the differences between the public Medicaid NCCI edit files and the Medicaid NCCI edit files that are posted on the secure RISSNET portal?
Access to the complete quarterly Medicaid NCCI edit files that are posted on the secure RISSNET portal is limited to a state’s Medicaid agency. These state Medicaid NCCI edit files contain information that is not included in the Medicaid NCCI edit files that are available to the public on the Medicaid NCCI webpage (i.e., MUEs that are no longer in effect, their effective date and deletion date, the effective date of current MUEs, and the CLEID for PTP edits and MUEs).
Why can’t the States use the public Medicaid NCCI edit files to process their Medicaid claims?
SMAs must ensure that they or their vendor are using the appropriate Medicaid NCCI edits to adjudicate Medicaid claims. The publicly available files on the NCCI Medicaid webpages are for providers and the general public. States cannot use the publicly available files for processing and paying Medicaid claims. NCCI edit files available on the RISSNET secure portal contain additional information necessary for correct claims processing by SMAs. SMA use of the publicly available files that do not contain edit history may result in improper payment or inappropriate denials. The public files do not contain the Correspondence Language Example Identifiers (CLEID) contained in the files on the RISSNET secure portal. CLEIDs support the rationale for each edit during the claims processing and adjudication process. General information on CLEIDs and examples of CLEIDs are available in the NCCI Correspondence Language Manual for Medicaid Services on the Medicaid NCCI Reference Documents webpage.
Can State Medicaid Agencies share NCCI data files obtained through the secure Regional Information Sharing System portal with vendors or other contracted parties?
A state Medicaid agency may share these quarterly state Medicaid NCCI edit files, which are posted on the secure Regional Information Sharing System (RISSNET) portal, with the contracted fiscal agent that processes its FFS claims or with any of its contracted Medicaid managed-care entities that are using the Medicaid NCCI methodologies in its processing of claims or encounter data, if appropriate confidentiality agreements are in place. The state Medicaid agency, its fiscal agent, and its managed-care entities may also share those files at that time with any contractor or subcontractor (including, but not limited to, COTS software vendors) that is assisting with the implementation of the state’s Medicaid NCCI program in the processing of claims or encounter data, only when appropriate confidentiality agreements are in place. The state Medicaid agency need not have a direct contract with such vendors.
A state Medicaid agency may share quarterly state Medicaid NCCI edit files with state auditors, if appropriate confidentiality agreements are in place.
Where can I find additional guidance on NCCI edits in Medicaid?
Learn to navigate the CMS Medicaid NCCI webpages, work with Medicaid Procedure-to-Procedure (PTP) edits, and Medically Unlikely Edits (MUE). Find information on how to access and use the Medicaid NCCI files available to the general public. Note that Medicare NCCI Program has significant differences from the Medicaid NCCI program.
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.