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.
Care managers often do not document data elements in the assessment and care plan measures unless the member has "a problem." For example, they may not document that they assessed the member's vision or need for an assistive device if no problem was identified. How can states or plans address this issue?
Managed Long Term Services and Supports (MLTSS) plan managers should provide training on proper documentation practices to care managers and other delegated staff. States and MLTSS plans could consider including data field entry options to remind care managers to record all results of the assessment, even if findings are negative, that is, the member does not have a problem or need assistance or services. For example, states and plans could include a question in the member’s record that requires the care manager to document both whether an assessment was performed and whether a problem was identified, along with another required field to include the details of the problem if there was a problem identified.
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.
Our state uses multiple cost centers (routine and ancillary) in the calculation of our inpatient hospital Upper Payment Limit (UPL). Do the templates permit the use of multiple cost centers?
Yes, the templates allow the use of multiple cost centers. For example, if the state uses a cost methodology for ancillary services and a per-diem methodology for routine services, the state will complete one cost template and one per-diem template in order to account for these two cost centers. Every hospital would be featured in each of the two templates; however, to differentiate their provider information, the state would append the Medicare Certification Number (Medicare ID) (variable 112) with a letter, such as an -A or a -B. For example, if the Medicare ID was 123456, it would be depicted in the cost template as 123456-A and in the per diem template as 123456-B. If a Medicare Certification Number is not available then the state should append the Medicaid Provider Number. If there are multiple cost centers under either the cost or per-diem methodology, the state would separate out the cost centers within their respective templates. Each cost center should be associated with only one appended letter and these should be described in the notes tab. When using multiple cost centers, the state should insert a new tab in the templates that summarizes the UPL gap calculations for each of the ownership categories (state government owned, non-state government owned, and private), unless a summary worksheet is already included in the workbook.
Our state uses multiple cost centers with varying cost-to-charge ratios in our calculation of the inpatient hospital Upper Payment Limit (UPL). Does the template accommodate this?
Yes, the template allows the use of multiple cost centers with multiple cost-to-charge ratios. The state would separately report the costs and payments associated with each of the cost centers in the cost template. To differentiate the cost centers, the state would append the Medicare Certification Number (Medicare ID) (variable 112) with a letter, for example an -A, -B, or -C, that would be used as a unique identifier for each cost center.
Our state uses multiple methodologies for the three ownership categories in the calculation of our inpatient hospital Upper Payment Limit (UPL). Do the templates permit the use of multiple methodologies?
Yes, the templates allow the use of multiple methodologies. The state would complete the templates associated with the UPL methodologies used. For example, if the state uses a cost-based methodology for state owned hospitals and a payment-based methodology for private hospitals, then the state would complete the cost template for the state owned hospitals and the payment template for the private hospitals. When using multiple methodologies, the state should insert a new tab in the templates that summarizes the UPL gap calculations for each of the ownership categories (state government owned, non-state government owned, and private), unless a summary worksheet is already included in the workbook.
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 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.
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, 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.
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.