NCCI Methodologies in Medicaid

The Medicaid National Correct Coding Initiative (NCCI) program consists of six methodologies.

  1. Procedure-to-Procedure (PTP) edits for practitioner and ambulatory surgical center (ASC) services
  2. PTP edits for outpatient services in hospitals (including emergency department, observation, and hospital laboratory services)
  3. PTP edits for durable medical equipment
  4. Medically Unlikely Edits (MUEs) for practitioner and ASC services
  5. MUEs for outpatient services in hospitals
  6. 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.

Components of the NCCI Methodologies in Medicaid

Each of the Medicaid NCCI methodologies has four components.

  1. A set of edits
  2. Definitions of types of claims subject to the edits
  3. A set of claim adjudication rules for applying the edits
  4. 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 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.