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
Upon analysis by states, what if one or more edits are found that are necessary to improve correct coding within a state's Medicaid program, but are not currently included within an National Correct Coding Initiative (NCCI) methodology?
States are free to apply their own edits, in addition to the Medicaid NCCI edits, that meet the intent of the statute and would improve correct coding within their Medicaid programs. However, these state-specific edits should not be characterized as NCCI edits. If such state edits result in additional savings to the state's Medicaid program by promoting correct coding and reducing the error rate for claims payments, the state should recommend that the CMS add these edits to one or more of the sets of Medicaid NCCI edits.
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in the Medicaid NCCI edit files that are available to the public on the Medicaid NCCI webpage (i.e., MUEs that are no longer in effect, their effective date and deletion date, the effective date of current MUEs, and the CLEID for PTP edits and MUEs).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 are National Correct Coding Initiative (NCCI) methodologies for the Medicaid program?
The Medicaid National Correct Coding Initiative (NCCI) program consists of six methodologies.
- Procedure-to-Procedure (PTP) edits for practitioner and ambulatory surgical center (ASC) services
- PTP edits for outpatient services in hospitals (including emergency department, observation, and hospital laboratory services)
- PTP edits for durable medical equipment
- Medically Unlikely Edits (MUEs) for practitioner and ASC services
- MUEs for outpatient services in hospitals
- MUEs for durable medical equipment
The Medicaid NCCI methodologies apply only to Medicaid fee-for-service claims that are reimbursed based on the Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes.
Each of the Medicaid NCCI methodologies has four components.
- A set of edits
- Definitions of types of claims subject to the edits
- A set of claim adjudication rules for applying the edits
- A set of rules for addressing provider appeals of denied payments for services based on the edits
Information on claim adjudication rules for applying the Medicaid NCCI methodologies in state processing of Medicaid claims, the third component of the Medicaid NCCI methodologies, is contained in appendices B and C of the Medicaid NCCI Technical Guidance Manual.
State Medicaid Director Letter (PDF, 159.55 KB) states the Center for Medicare & Medicaid Services (CMS) policy on provider appeals of payments of Medicaid claims denied due to the Medicaid NCCI edits, the fourth component of the Medicaid NCCI methodologies.
Upon analysis by states, what if an edit is found to be in conflict with a state law or regulation, but is currently included within a National Correct Coding Initiative (NCCI) methodology?
The CMS allows states to consider edits on an individual, state-by-state basis. If a state determines that an edit in the Medicaid NCCI methodologies conflicts with one or more state laws, regulations, administrative rules, or payment policies, the state can request permission from the CMS to deactivate the conflicting edit. States are not afforded the flexibility to deactivate edits after March 31, 2011, due to a lack of operational readiness.
If a state determines and documents that there is no other feasible way to comply with Medicaid NCCI edits, the state can send a request to deactivate that edit or those individual edits using the NCCI mailbox at NCCIPTPMUE@cms.hhs.gov. The request must include sufficient primary source documentation of the conflicting state law, regulation, administrative rule, or payment policy. States are no longer required to send NCCI deactivation requests to the CMS Regional Offices.
Both the State Medicaid Director Letter describing the Substance Use Disorder (SUD) section 1115 demonstration opportunity and the Centers for Medicare & Medicaid Services (CMS) SUD Implementation Plan template, reference needs assessment tools and program standards established by the American Society for Addiction Medicine (ASAM). Is a state required to reference or rely on the ASAM Criteria in implementing an SUD section 1115 demonstration?
No, a state is not required to reference or rely on the ASAM Criteria however, states should use guidelines/patient placement tools that are comparable to ASAM criteria. The State Medicaid Director Letter describing the SUD section 1115 demonstration opportunity references the ASAM Criteria as a recognized standard and an example of a patient placement assessment tool that states could use. Participating states are expected to ensure that providers use an SUD-specific, multi-dimensional assessment tool in determining the types of treatments and level of care a beneficiary with an SUD may need. The ASAM Criteria is referenced as a representative example of such an assessment tool.
Some states proposed alternative needs assessment tools. CMS reviews each alternative proposal on an individual basis, and CMS has so far determined that those alternatives are comparable to the ASAM Criteria and meet the expectations for this demonstration initiative. In addition, participating states are expected to implement provider qualifications for residential treatment providers that reflect well-established standards for these treatment settings. Again, the ASAM Criteria is referenced as an example of a resource that states may use for determining those standards.
Where can I find an application to apply for the Medicare Savings Program (MSP)?
The Medicare Savings Program (MSP) Model application can be found here: Medicare Savings Programs (MSP) Model Application for Medicare Premium Assistance
Do the data elements comprising the falls risk assessment need to be documented as part of a comprehensive assessment?
No. Although a comprehensive assessment may include falls risk assessment elements, this measure does not require the risk assessment elements to be documented as part of a comprehensive assessment. For this measure, a falls risk assessment is considered complete if the member record includes any documentation of a balance/gait assessment, and documentation of assessment of postural blood pressure, vision, home fall hazards, and/or medications.