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* Person-Centered Hospital Discharge Model
* Person-Centered Planning Grants
* State Profile Tool Grant
* Balancing Long Term Services & Supports
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* Institutional Long Term Care
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* Self-Directed Services
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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.
FAQ LIBRARY
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WHAT ARE THE DIFFERENCES BETWEEN THE PUBLIC MEDICAID NCCI EDIT FILES AND THE
MEDICAID NCCI EDIT FILES THAT ARE POSTED ON THE SECURE RISSNET PORTAL?
May 25, 2021
Access to the complete quarterly Medicaid NCCI edit files that are posted on the
secure RISSNET portal is limited to a state’s Medicaid agency. These state
Medicaid NCCI edit files contain information that is not included in the
Medicaid NCCI edit files that are available to the public on the Medicaid NCCI
webpage (i.e., MUEs that are no longer in effect, their effective date and
deletion date, the effective date of current MUEs, and the CLEID for PTP edits
and MUEs).
FAQ ID:108651
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WHY CAN’T THE STATES USE THE PUBLIC MEDICAID NCCI EDIT FILES TO PROCESS THEIR
MEDICAID CLAIMS?
May 25, 2021
SMAs must ensure that they or their vendor are using the appropriate Medicaid
NCCI edits to adjudicate Medicaid claims. The publicly available files on the
NCCI Medicaid webpages are for providers and the general public. States cannot
use the publicly available files for processing and paying Medicaid claims. NCCI
edit files available on the RISSNET secure portal contain additional information
necessary for correct claims processing by SMAs. SMA use of the publicly
available files that do not contain edit history may result in improper payment
or inappropriate denials. The public files do not contain the Correspondence
Language Example Identifiers (CLEID) contained in the files on the RISSNET
secure portal. CLEIDs support the rationale for each edit during the claims
processing and adjudication process. General information on CLEIDs and examples
of CLEIDs are available in the NCCI Correspondence Language Manual for Medicaid
Services on the Medicaid NCCI Reference Documents webpage.
FAQ ID:108656
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CAN STATE MEDICAID AGENCIES SHARE NCCI DATA FILES OBTAINED THROUGH THE SECURE
REGIONAL INFORMATION SHARING SYSTEM PORTAL WITH VENDORS OR OTHER CONTRACTED
PARTIES?
May 25, 2021
A state Medicaid agency may share these quarterly state Medicaid NCCI edit
files, which are posted on the secure Regional Information Sharing System
(RISSNET) portal, with the contracted fiscal agent that processes its FFS claims
or with any of its contracted Medicaid managed-care entities that are using the
Medicaid NCCI methodologies in its processing of claims or encounter data, if
appropriate confidentiality agreements are in place. The state Medicaid agency,
its fiscal agent, and its managed-care entities may also share those files at
that time with any contractor or subcontractor (including, but not limited to,
COTS software vendors) that is assisting with the implementation of the state’s
Medicaid NCCI program in the processing of claims or encounter data, only when
appropriate confidentiality agreements are in place. The state Medicaid agency
need not have a direct contract with such vendors.
A state Medicaid agency may share quarterly state Medicaid NCCI edit files with
state auditors, if appropriate confidentiality agreements are in place.
FAQ ID:108676
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WHERE CAN I FIND ADDITIONAL GUIDANCE ON NCCI EDITS IN MEDICAID?
May 25, 2021
How To Use The Medicaid National Correct Coding Initiative (NCCI) Tools
Learn to navigate the CMS Medicaid NCCI webpages, work with Medicaid
Procedure-to-Procedure (PTP) edits, and Medically Unlikely Edits (MUE). Find
information on how to access and use the Medicaid NCCI files available to the
general public. Note that Medicare NCCI Program has significant differences from
the Medicaid NCCI program.
FAQ ID:108681
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WHAT GUIDANCE DID STATE MEDICAID DIRECTOR LETTER (SMDL) #10-017 IMPLEMENT?
May 25, 2021
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".
FAQ ID:94991
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WHAT DOES SECTION 6507 OF THE AFFORDABLE CARE ACT REQUIRE OF STATE MEDICAID
PROGRAMS, WITH REGARDS TO THE NATIONAL CORRECT CODING INITIATIVE (NCCI)?
May 25, 2021
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
the 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.
The 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, the 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.
The 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.
FAQ ID:94996
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WHAT IS THE NATIONAL CORRECT CODING INITIATIVE (NCCI)?
May 25, 2021
The NCCI is a CMS program that consists of coding policies and edits. Providers
report procedures / services performed on beneficiaries utilizing Healthcare
Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT)
codes. These codes are submitted on claim forms to fiscal agents for payment.
NCCI policies and edits address procedures / services performed by the same
provider for the same beneficiary on the same date of service.
This program was originally implemented in the Medicare program in January 1996
to ensure accurate coding and reporting of services by physicians. The coding
policies of NCCI are based on coding conventions defined in the American Medical
Association's Current Procedural Terminology Manual, national and local Medicare
policies and edits, coding guidelines developed by national societies, standard
medical and surgical practice, and / or current coding practice.
FAQ ID:95001
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WITH REGARDS TO THE NATIONAL CORRECT CODING INITIATIVE (NCCI), WHAT IF A NEW
METHODOLOGY IS DISCOVERED THAT WAS NOT IDENTIFIED IN SMDL #10-017?
May 25, 2021
The CMS fully anticipates, and will continue to evaluate the application of,
additional NCCI methodologies and / or edits that will achieve additional
savings that are possible as a result of proper coding. Additional methodologies
may be developed later and, if so, the CMS will update states regarding the
progress of NCCI methodologies in Medicaid moving forward. An example of this
are the NCCI Procedure-to-Procedure (PTP) edits for DME which were implemented
in the Medicaid NCCI Program in October 2012.
FAQ ID:95006
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WHAT IS A NATIONAL CORRECT CODING INITIATIVE (NCCI) EDIT AND HOW DOES IT DIFFER
FROM AN NCCI METHODOLOGY?
May 25, 2021
NCCI edits are one component of the NCCI methodologies. The 6 Medicaid NCCI
methodologies contain approximately 3 million Procedure-to-Procedure (PTP) edits
and Medically Unlikely Edits (MUEs) as of March 2017. The NCCI edits are defined
as edits applied to claims for services performed by the same provider, for the
same beneficiary, on the same date of service. Providers report procedures /
services performed on beneficiaries utilizing HCPCS / CPT codes. These codes are
submitted on claim forms to fiscal agents for payment.
The NCCI methodologies contain 2 types of edits:
1. NCCI procedure-to-procedure (PTP) edits define pairs of HCPCS / CPT codes
that should not be reported together for a variety of reasons. These edits
consist of a Column One code and a Column Two code. If both codes are
reported, the Column One code is eligible for payment and payment for the
Column Two code is denied. However, each PTP edit has an assigned modifier
indicator, which provides information on whether a PTP-associated modifier
may be used to bypass the edit, in appropriate circumstances, and allow
payment for both the Column One and Column Two codes. An indicator of "0"
means that a modifier cannot be used to bypass the edit. An indicator of "1"
means that a PTP associated modifier, such as 25, 59, RT, LT, etc., may be
used, if appropriate, to bypass the edit. An indicator of "9" means the edit
has been deleted and the modifier indicator is not relevant.
2. Medically Unlikely Edits (MUEs) define for many HCPCS / CPT codes the
maximum number of units of service (UOS) that are under most circumstances
billable by the same provider, for the same beneficiary, on the same date of
service. Reported UOS greater than the MUE value are unlikely to be correct
(e.g., a claim for excision of more than one gallbladder or more than one
pancreas). Billed claim lines with a unit-of-service value greater than the
established MUE value for the HCPCS / CPT code are denied payment in their
entirety.
FAQ ID:95011
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WHAT DOES THE CMS PROVIDE TO STATES IN ORDER TO IMPLEMENT NATIONAL CORRECT
CODING INITIATIVE (NCCI) IN MEDICAID?
May 25, 2021
The CMS provides states the Medicaid NCCI edit files for downloading on a
quarterly basis approximately 45 days before the beginning of a new calendar
quarter. These files are available for downloading by states on the Medicaid
Integrity Institute (MII) website on a secure portal (RISSNET). The files are
available in 3 file formats: fixed-width ASCII text, tab-delimited ASCII text,
and Excel 2007. The files are complete replacements of the files for the
previous calendar quarters.
The following public documents are posted on the Medicaid NCCI pages:
* NCCI Edit Files. The most recent versions are posted in tab-delimited ASCII
text and Excel 2007 file formats. These documents are intended for use by
other interested parties (e.g., providers), not by state Medicaid agencies.
* Change Reports. These documents identify the changes to the NCCI edits from
the previous quarter to the current quarter. These reports are posted in
Excel 2007 and tab-delimited ASCII text formats.
* National Correct Coding Initiative Policy Manual for Medicaid Services. This
manual is helpful in understanding the policies on which the
Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs) are
based and will assist staffs in customer service, medical review, and
appeals.
* NCCI Correspondence Language Manual. This manual provides information about
the Correspondence Language Example Identification Number (CLEID), which is
associated with each PTP edit and MUE. The CLEID provides general information
about the rationale for the edits, which can be used to help educate
providers about the edits.
* Reports to Congress.
* Medicaid National Correct Coding Initiative Technical Guidance Manual. This
document provides information for state Medicaid agencies and fiscal agents
about NCCI policies.
FAQ ID:95016
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