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 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 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?
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 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 CMS Regional Offices.
Must the completion of a Managed Long Term Services and Supports (MLTSS) comprehensive care plan take place in the home?
No, for the LTSS Comprehensive Care Plan and Update measure, the care plan does not have to take place in the member’s home. However, it must be done face-to-face unless certain exceptions are met. These exceptions include circumstances in which:
- The member was offered a face-to-face discussion and refused (either refused a face-to-face encounter or requested a telephone discussion instead of a face-to-face discussion).
- The state policy, regulation, or other state guidance excludes the member from a requirement for face-to-face discussion of a care plan.
What if there are multiple Managed Long Term Services and Supports (MLTSS) LTSS Comprehensive Care Plan and Update care plans documented during the measurement period?
Use the most recently updated care plan.
How should a Managed Long Term Services and Supports (MLTSS) member's refusal to sign an LTSS Comprehensive Care Plan and Update plan be documented?
To meet the LTSS Comprehensive Care Plan and Update measure numerator, the care plan must be signed by the member, unless the care plan is under appeal in the specified timeframe, and there is documentation that the care plan was in appeal. There is an exclusion for members who refuse to take part in care planning. This exclusion is reported with the measure rate, so the overall measure rate can be interpreted correctly. For example, a plan that is not successful at engaging members in care planning, indicated by a high exclusion rate, would suggest the overall rate on the measure should be interpreted with caution.
What if a Managed Long Term Services and Supports (MLTSS) member could not be reached for the LTSS Comprehensive Care Plan and Update?
There must be documentation that at least three attempts were made to reach the member, and they could not be reached. The rate of exclusion due to inability to reach a member should also be reported along with the measure performance rate.
What if a Managed Long Term Services and Supports (MLTSS) member either does not have a caregiver involved or does not want their caregiver involved in the LTSS Comprehensive Care Plan and Update? What if a member's caregiver declines to participate in care planning?
In these circumstances, MLTSS plan records should clearly document that no caregiver was involved to satisfy the measure criteria. For example, there are situations in which it may not be appropriate to engage the caregiver, including cases in which the member refused to involve the caregiver, or the invited caregiver declined to participate. Reasons for lack of caregiver involvement are not required; documentation that a caregiver was not involved suffices.
If no deficit is identified for one of the core elements required for the care plan (for example, functional needs), what should the care plan contain?
For certain elements of the care plan, documentation of no deficit suffices to receive credit for the elements (for example, functional needs, medical needs, cognitive impairment needs). Other elements in the core and supplemental rates of the Managed Long Term Services and Supports (MLTSS) LTSS Comprehensive Care Plan and Update measure require documentation regardless of whether a deficit is identified (for example, individualized member goal, plan for follow-up and communication, plan for emergency). Refer to the details in the measure specification to identify where documentation of no deficit meets the element definition.
What are National Correct Coding Initiative (NCCI) methodologies and are these methodologies compatible with the Medicaid program?
The NCCI methodologies are made up of the following four components:
- Sets of edits
- Definitions of types of claims subject to the edits
- Sets of claim-adjudication rules for applying the edits
- Sets of rules for addressing provider/supplier appeals of denied payments for services based on the edits
The NCCI methodologies include both NCCI Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs).
CMS issued SMDL #11-003 (PDF, 159.55 KB) on April 22, 2011, to state CMS policy on the requirement for appeals of claims for which payment was denied due to an NCCI edit. The nature of the appeals process in each state is left to the discretion of the state's Medicaid agency.
CMS currently has six methodologies for Medicare Part B. These methodologes are the following:
- NCCI PTP edits for practitioner and ambulatory surgical center (ASC) services
- NCCI PTP edits for outpatient services (including emergency department, observation, and hospital laboratory services) in hospitals reimbursed through the hospital outpatient prospective payment system (OPPS). Edits are applied to all facility therapy services billed to the Medicare Fiscal Intermediary (Part A Hospital / Part B Practitioner Medicare Administrative Contractors processing claims with the Fiscal Intermediary Shared System).
- MUE units-of-service edits for practitioner and ASC services
- MUE units-of-service edits for outpatient services in hospitals
- MUE units-of-service edits for supplier claims for durable medical equipment
- Add-on code edits for practitioner and ASC services (added in April 2013).
After review, CMS determined that the first five NCCI methodologies listed above were compatible methodologies for claims filed in Medicaid. A sixth methodology for Medicaid was added in 2012: NCCI PTP edits for Durable Medical Equipment (DME).
What National Correct Coding Initiative (NCCI) methodologies did CMS find that are not compatible with Medicaid and that are currently being utilized in the Medicare program?
CMS determined that the five NCCI methodologies that were in place in Medicare in 2010 were compatible methodologies for claims filed in Medicaid and that these five methodologies must be incorporated in a state's Medicaid Management Information System (MMIS) for provider claims filed on and after October 1, 2010.
CMS works with the NCCI contractor to identify specific edits within the five methodologies which need to be modified or deleted for Medicaid. Also, edits are developed for the Medicaid NCCI program for services and items that are not covered or not separately payable by Medicare. CMS found that most state MMISs could not accommodate the add-on code edits used in Medicare. Therefore CMS provides those edits to the states for optional use as state-specific edits.
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 CMS add these edits to one or more of the sets of Medicaid NCCI edits.