The Center for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) promotes national correct coding methodologies and reduces improper coding which may result in inappropriate payments of Medicare Part B claims and Medicaid claims. Visit National Correct Coding Initiative Edits for information about, and edits for, the Medicare NCCI program. The Medicaid NCCI program has significant differences from the Medicare NCCI program.
The Affordable Care Act of 2010 required CMS to notify states by September 1, 2010, of the NCCI methodologies that were compatible with Medicaid. State Medicaid Director Letter (PDF, 133.63 KB) notified states that all five Medicare NCCI methodologies were compatible with Medicaid. The Affordable Care Act required state Medicaid programs to incorporate compatible NCCI methodologies in their systems for processing Medicaid claims by October 1, 2010.
Types of NCCI Edits
The NCCI contains two types of edits:
- NCCI procedure-to-procedure (PTP) edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons. The purpose of the PTP edits is to prevent improper payments when incorrect code combinations are reported.
- Medically Unlikely Edits (MUEs) define for each HCPCS/CPT code the maximum units of service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service.
CMS issued replacement files with the following changes:
- Replacement Files (2nd quarter of 2020) – related to the COVID-19 Public Health Emergency:
In accordance with Centers for Medicare & Medicaid Services’ (CMS) expansion of telehealth services, CMS updated procedure-to-procedure (PTP) edits and Medically Unlikely Edits (MUEs) for Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes. CMS issued replacement files for NCCI PTP PRA, NCCI PTP OPH, NCCI MUE PRA, and NCCI MUE OPH.
Per CMS’ announcement, effective for services starting March 6, 2020, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances. Although NCCI files have dates consistent with the first day of each quarter and are therefore dated retroactive to January 1, 2020, Medicare payments based on the expansion of telehealth services are for dates of services starting March 6, 2020. CMS provided a complete list of all Covered Telehealth Services for PHE for the COVID-19 pandemic. Updated public replacement files for Medicaid are available on the Edit Files page.
Physicians, hospitals and other providers must report services correctly and code correctly even in the absence of NCCI or OCE edits. (Announcement posted May 14, 2020)
- CMS is temporarily deleting procedure-to-procedure (PTP) edits with several radiopharmaceuticals retroactive to January 1, 2020. (Announcement Posted February 28, 2020)
- Healthcare Common Procedure Coding System (HCPCS) codes G2061, G2062, and G2063 replaced G2029, G2030 and G0231 respectively, effective January 1, 2020. (Announcement posted February 4, 2020)
- CMS made the decision to retain the edits that were in effect prior to January 1, 2020, and to delete the January 1, 2020 PTP edits for Current Procedural Terminology (CPT) code pairs 97530 or 97150/97161, 97530 or 97150/97162, 97530 or 97150/97163, 97530 or 97150/97165, 97530 or 97150/97166, 97530 or 97150/97167, 97530 or 97150/97169, 97530 or 97150/97170, 97530 or 97150/97171, and 97530 or 97150/97172. (Announcement posted February 4, 2020)
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. States must ensure that they or their vendor are using the appropriate Medicaid NCCI edits to adjudicate Medicaid claims.
Revised annual versions of the Medicaid NCCI Policy Manual and the Medicaid NCCI Technical Guidance Manual effective January 1, 2020, are available on the Reference Documents webpage.
As part of the January 1, 2020 revision to the Medicaid NCCI Technical Guidance Manual, CMS has clarified that states are not required to submit to CMS estimates of savings from applying Medicaid NCCI methodologies. However, if a state would like to estimate savings for internal purposes, the state may consult the NCCI MUE/PTP Edit Savings Guidance for State Medicaid Agencies, available in the Reference Documents section of the NCCI Medicaid website.
Section 6507 of the Affordable Care Act requires states to use “compatible” NCCI methodologies in paying applicable Medicaid claims. 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 to the NCCI Contractor using the NCCI mailbox at NCCIPTPMUE@cms.hhs.gov. States are no longer required to send NCCI deactivation requests to CMS Regional Offices.
Please note that CMS no longer participates in the National Medicaid Enterprise Hub (NMEH) calls. However, states can continue to obtain information on the NCCI program using the NCCI Medicaid website and the NCCI Mailbox at NCCIPTPMUE@cms.hhs.gov. As an alternative, states can contact their State Program Integrity Directors for the Fraud Waste and Abuse (FWA) Technical Advisory Group (TAG) calls information. However, only state staff (no contractors) can attend TAG calls.
NCCI Contact Information
This webpage provides information to states, providers, and other interested parties regarding implementation of the NCCI methodologies in the Medicaid program.
Inquiries about the NCCI program, including those related to NCCI (PTP, MUE and Add-On) edits, should be sent to NCCIPTPMUE@cms.hhs.gov.
If the viewer has concerns about specific NCCI edits, they may submit comments in writing to:
National Correct Coding Initiative Contractor
P.O. Box 368
Pittsboro, IN 46167