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 funding is available to states to implement section 6507 of the Affordable Care Act?
Section 1903(r) of the Social Security Act (the Act), as amended by section 6507 of the Affordable Care Act, describes the functionality of a state's MMIS system or a state's information retrieval and automated claims-payment processing system. With the enactment of this section, state MMISs must include Medicaid NCCI methodologies as part of their functionality. Section 1903(a)(3) of the Act provides the CMS with the authority to provide enhanced federal financial participation (FFP) to states for the design, development, installation, and maintenance of the state's MMIS. Thus, in considering revisions to a state's MMIS, the CMS is authorized to provide 90 percent FFP to states to incorporate Medicaid NCCI methodologies into the state's MMIS.
The CMS will utilize the current Advanced Planning Document (APD) process for states to request such funding for a state's MMIS. States should work with their respective CMS Regional Offices to request enhanced FFP through submission of a Medicaid NCCI APD.
With regards to National Correct Coding Initiative (NCCI), are all Medicaid Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs) published and available to states and providers on the CMS website?
All currently active and previously active Medicaid Procedure-to-Procedure (PTP) edits are published on the Medicaid.gov website for use by the general public and interested parties. Medicaid Medically Unlikely Edits (MUEs) that are active for dates of service in the current quarter are published on the Medicaid.gov website for use by the general public and interested parties; previous MUEs with deletion dates prior to the current quarter are not included.
States and providers must be aware that there are a number of differences between Medicaid and Medicare NCCI edits. For example:
- Medicare has some non-published / confidential MUEs. However, there are no confidential or non-published edits in the Medicaid NCCI program at this time.
- MUEs for the same code may have different values in the Medicare and Medicaid NCCI programs.
- The Medicaid NCCI program has PTP edits for durable medical equipment; the Medicare NCCI program does not.
- The Medicaid NCCI program has PTP edits and MUEs for codes that are not covered or not separately payable by the Medicare program.
It is important that providers and others use the correct website to obtain the Medicaid PTP edit and MUE files. Providers and others sometimes access the Medicare NCCI section of the CMS.gov website to obtain the NCCI edit files, rather than the Medicaid NCCI section of the Medicaid.gov website. It is important to note, there are 2 separate NCCI pages, 1 for each program. Conducting a general search of "NCCI" or "National Correct Coding Initiative" directly from the CMS.gov website will take the user to the Medicare page, not the Medicaid page. Providers and others should go to the Medicaid.gov website to obtain Medicaid-related NCCI information and edit files.
States must download the NCCI edit files that are available on the Medicaid Integrity Institute (MII) website using a secure portal (RISSNET) rather than using the publicly available files from the Medicaid.gov website. States must ensure that they or their vendor are using the appropriate Medicaid NCCI edits to adjudicate Medicaid claims.
If a provider receives a denial that is attributed to an NCCI Procedure-to-Procedure (PTP) edit or Medically Unlikely Edits (MUEs), can the provider verify the edit on the Medicaid NCCI webpage on the Medicaid.gov website?
As discussed above, all currently active Medicaid PTP edits and MUEs are published on the Medicaid NCCI webpage on the Medicaid.gov website - i.e., all edits that are applicable to claims with dates of service in the current calendar quarter:
- The PTP edit files that are posted on the Medicaid.gov NCCI webpage also contain historical information - i.e., they contain the effective date of every edit and the deletion date of prior edits. This information can be used to verify whether a particular PTP edit was valid on the date of service (DOS) of the claim in question and whether use of a PTP-associated modifier would allow the claim to bypass the edit.
- The MUE files on the Medicaid.gov NCCI webpage identify the edits that are applicable to claims processed in the current quarter and with dates of service in the current quarter. They do not contain historical information - i.e., they do not contain the effective dates of current edits nor do they include prior edits that have been deleted or revised. However, that information is available to the states in the files that a state downloads from the MII website using a secure portal (RISSNET). Providers who want to verify whether there was an MUE and what the value was for that MUE on a DOS prior to the current quarter would need to contact the state.
As discussed above, it is imperative that providers access the Medicaid NCCI edit files on the Medicaid NCCI webpage on the Medicaid.gov website and not the Medicare NCCI edit files, as there are significant differences between the 2 sets of files.If providers are reporting NCCI-related denials that are not appearing in the Medicaid NCCI edit files, the state should contact their vendor or check their system to determine the origin of the edit. If the edit is not part of the Medicaid NCCI PTP editor MUE file sets, the denial may not be attributed to NCCI. States have the flexibility to create other Procedure-to-Procedure edits or units-of-service edits, but should be using state-specific denial messages for these edits, not NCCI-related denial messages.
Can denials resulting from National Correct Coding Initiative (NCCI) edits be appealed?
A provider impacted by an NCCI-related claim denial shall be subject to the standard state appeals or claim resubmission process(es). States are not required to have a formal appeals process to address claim denials. However, states must ensure that providers have an adequate opportunity to alert them to potential errors associated with claim denials, including those generated by NCCI edits, and that providers have an avenue to resubmit claims or provide additional documentation to support their claims.
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 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.