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Frequently Asked Questions

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.

FAQ Library

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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.

FAQ ID:95166

Should I include discharges resulting in readmission to the institution in the Long Term Services and Supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator?

No, discharges that result in readmission to the institution within 60 days of discharge from the institution do not meet the LTSS Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator criteria.

FAQ ID:91146

When counting the duration of a member's stay for the long term services and supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator calculation, should I include the day of discharge?

Do not count the day of discharge unless the member’s admission and discharge occurred on the same day. If the admission and discharge occurred on the same day, the number of days in the stay is equal to one.

FAQ ID:91156

If there is no discharge, how should I calculate the length of stay for the long term services and supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measure numerator?

If there is no discharge, calculate the length of stay as the date of the last day of the measurement year minus the institutional facility admission date.

FAQ ID:91166

Are the long term services and supports (LTSS) Minimizing Institutional Length of Stay and LTSS Successful Transition after Long-Term Institutional Stay measures risk-adjusted?

Yes, the LTSS Minimizing Institutional Length of Stay and LTSS Successful Transition after Long- Term Institutional Stay measures are risk-adjusted based on the members’ dual eligibility status, age and gender, diagnoses from the institutional facility admission, and number of hospital stays and months of enrollment in the classification period. See the risk adjustment weights needed for these measures are in the risk adjustment tables (XLSX, 59.69 KB).

FAQ ID:91171

Should a member's admission be included in the Long Term Services and Supports (LTSS) Successful Transition after Long-Term Institutional Stay measure denominator if it was a direct transfer from another institution?

No, do not include these admissions in the LTSS Successful Transition after Long-Term Institutional Stay measure denominator.

FAQ ID:91176

Would an admission to an institutional facility following a discharge from another facility two days prior be considered a direct transfer?

No, these would be two distinct institutional stays; do not remove this admission from the Long Term Services and Supports Successful Transition after Long-Term Institutional Stay measure denominator.

FAQ ID:91186

How should I account for a member's death when calculating the Long Term Services and Supports Successful Transition after Long-Term Institutional Stay member's numerator and denominator?

If the member died in the institution or within one day of discharge from the institution, do not include their admission in the denominator. Members who died one day after discharge are excluded because of the high number of deaths the day after discharge observed while testing this measure; such members are unlikely to have been discharged alive. If the member died between day 2 and day 60 during the 60 days following discharge from the long-term institutional stay, do not include their discharge in the numerator.

FAQ ID:91191

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:

  1. Sets of edits
  2. Definitions of types of claims subject to the edits
  3. Sets of claim-adjudication rules for applying the edits
  4. 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:

  1. NCCI PTP edits for practitioner and ambulatory surgical center (ASC) services
  2. 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).
  3. MUE units-of-service edits for practitioner and ASC services
  4. MUE units-of-service edits for outpatient services in hospitals
  5. MUE units-of-service edits for supplier claims for durable medical equipment
  6. 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).

FAQ ID:95121

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.

FAQ ID:95131

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