What is the Medicaid NCCI?

The CMS National Correct Coding Initiative (NCCI) promotes national correct coding methodologies and reduces improper coding, which may result in inappropriate payments of Medicaid claims.

The Medicaid NCCI includes 2 types of edits:

1. Procedure to Procedure (PTP) Edits define pairs of HCPCS and CPT codes that providers shouldn’t report together for various reasons. PTP edits prevent improper payments when incorrect code combinations are reported. Each edit has a Column One and a Column Two HCPCS/CPT code. If a provider reports the 2 codes of an edit pair for the same patient on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied, unless an appropriate modifier is used. We’ll learn more about modifiers later.
2. Medically Unlikely Edits (MUEs) define the maximum units of service (UOS) for each HCPCS/CPT code that a provider would report under most circumstances for a single patient on a single date of service. MUEs prevent payment for an inappropriate number or quantity of the same service on a single day.

Background

Per the Social Security Act, states’ Medicaid programs must incorporate compatible NCCI methodologies in their systems for processing Medicaid claims. The 6 methodologies are:

1. PTP edits for practitioner and ambulatory surgical center (ASC) services
2. PTP edits for outpatient services in hospitals (including services offered in emergency and radiology departments, observation units, clinics, and laboratories)
3. PTP edits for durable medical equipment (DME)
4. MUEs for practitioner and ASC services
5. MUEs for outpatient services in hospitals
6. MUEs for DME

The Medicaid NCCI methodologies apply only to Medicaid Fee-for-Service (FFS) claims paid based on HCPCS/CPT codes. This includes claims paid on a FFS basis in State Medicaid Primary Care Case Management managed care programs. Application of NCCI methodologies to FFS claims processed by limited benefit plans or Managed Care Organizations (MCOs) is desirable but optional.

Why Would a Medicaid Health Care Professional or Provider Use the Medicaid NCCI Webpage, Tables, and Manual?

Correct coding and reporting of services are critical aspects of proper billing. Providers can’t bill Medicaid patients for a service denied based on Medicaid PTP code pair edits or MUEs. NCCI documents on The National Correct Coding Initiative in Medicaid webpage help providers avoid coding and billing errors that lead to payment denials.

How Current are the Medicaid NCCI Tables?

The complete updated Medicaid NCCI edit files are publicly available on the Medicaid NCCI Edit Files webpage at the beginning of each calendar quarter. New edit files replace the Medicaid NCCI edit files from previous calendar quarters. The presence of a HCPCS/CPT code in a PTP edit or an MUE value for a HCPCS/CPT code doesn’t mean that any or all state Medicaid programs cover that code. Individual SMAs may have state-specific edits that aren’t NCCI edits.

Note: SMAs must download NCCI edit files available on the secure Regional Information Sharing System (RISSNET) portal rather than using the publicly available files on Medicaid.gov because SMAs must make sure they or their vendor use the correct Medicaid NCCI edits to resolve Medicaid claims. The publicly available files on the NCCI Medicaid webpages are for providers and the general public. States can’t use the publicly available files for processing and paying Medicaid claims. NCCI edit files on the RISSNET secure portal have more information needed for SMAs’ correct claims processing. SMA use of the public files that don’t have edit history may result in improper payment or incorrect denials. The public files don’t have the Correspondence Language Example Identifiers (CLEIDs) that are in the files on the RISSNET secure portal. CLEIDs provide information to SMAs and fiscal agents about the rationale for NCCI edits that can be used by states to help educate providers about the edits. Visit the Medicaid NCCI Correspondence Language Manual for general information and examples of CLEIDs.

How to Find the Medicaid NCCI Tables and Medicaid NCCI Manuals

Visit the Medicaid NCCI Reference Documents webpage to review the Medicaid NCCI Policy Manual, the Medicaid NCCI Technical Guidance Manual (TGM), and the Medicaid NCCI Correspondence Language Manual. You’ll find more information in the Manuals section.

Visit the Medicaid NCCI Edit Files webpage to search or download the files.

Using the Medicaid NCCI Tools

To look up an edit, first choose the Edit Files link in the menu on the left side of The National Correct Coding Initiative in Medicaid webpage as shown in Figure 1.

You’ll see the Medicaid NCCI Edit Files webpage as shown in Figure 2.

This webpage includes links to Medicaid NCCI edits for DME Services, Outpatient Hospital Services, and Practitioner Services for the current and previous quarters. Choose a link to review the most recent quarter of the NCCI PTP edits or MUEs.

Let’s start with a review of the Medicaid PTP edit files.

Looking up PTP Code Pair Edits

Go to the Medicaid NCCI Edit Files webpage. Choose the NCCI PTP Edits link, for the services you want, under the Complete Medicaid NCCI Edit Files heading. We are using the NCCI Procedure to Procedure (PTP) Edits Quarter Beginning 04/01/2022 dataset for Practitioner Services as the example for this educational tool but remember that you will select a link and data with the most recent date. Figure 3 shows the top of the NCCI Procedure to Procedure (PTP) Edits webpage for Practitioner Services for the quarter beginning 04/01/2022.

The dataset webpage offers information about the edit files, including the number of rows and columns.

You’ll find links to PTP edit files for the previous quarter at the bottom of the Medicaid NCCI Edit Files webpage.

How to Use PTP Code Pair Edits

The Column One and Column Two columns in the edit files show PTP code pairs. We’ll show how to use the PTP code pair tables with example code 99215. Our examples using the Medicaid NCCI PTP Edits tables and code 99215 will show:

What are the Column One and Column Two PTP code pair tables?

The Column Two code often is part of a more comprehensive Column One code. But this isn’t true for many edits. In some types of edits, the PTP code pair edit simply means 2 codes that providers shouldn’t report together, unless you use the correct modifier.

Don’t report certain procedure codes together when they’re mutually exclusive of each other. Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter.

Examples of mutually exclusive procedures:

• When there are different codes for different methods to repair an organ, a provider can only report 1 method to repair the organ.
• A provider can’t report an initial “per day” service and a “subsequent” “per day” service for the same date of service. For example, a provider shouldn’t report Skilled Nursing Facility Evaluation and Management service 99304 (Initial nursing facility care, per day) and 99307 (Subsequent nursing facility care, per day) together on the same day for the same patient by the same practitioner.

When is a code the reimbursable code of a PTP code pair?

The Medicaid NCCI PTP code tables include Column One and Column Two code pairs. If a provider reports the 2 codes of an edit pair on a claim for payment for the same patient on the same date of service, the Column One code is eligible for payment and the Column Two code is denied. But if both codes are clinically appropriate and the edit allows the use of an appropriate NCCI PTP-associated modifier, Medicaid will pay for the codes in both columns. The patient’s medical record must include supporting documentation.

You can find out when example code 99215 is the reimbursable code of a PTP code pair by opening an edit file link and using the Filter data button to search for 99215 in the Column One column. (More information about the filter tool is in the Filtering the NCCI Data Tables section.)

Figure 4 shows part of the our example NCCI Procedure to Procedure (PTP) Edits Quarter Beginning 04/01/2022 edit files for Practitioner Services, with example code 99215 in the Column One column.

1. Quarter Begin Date: The first date that this quarterly edit file is effective
2. Category: The category of service
3. Column One: Shows the payable code
4. Column Two: Shows the code that isn’t payable with this particular Column One code, unless an appropriate modifier is allowed and used
5. Effective Date: Shows the effective date of the PTP edit (month, day, year)
6. Deletion Date: Deletion date of the PTP edit
7. Modifier Indicator: Shows if a modifier is allowed to override the PTP edit (Modifier indicators are defined later in this section.)
8. PTP Edit Rationale: Shows the rationale for each PTP edit

Our search shows a portion of all Column One and Column Two PTP code pairs where 99215 is the payable code and every code that isn’t separately payable when you report it with 99215 (unless a modifier is allowed) based on the Column One or Column Two edits.

Figure 4 shows, for example, that a provider isn’t reimbursed for code 0362T (Behavior identification supporting assessment for patient exhibiting destructive behavior, each 15 minutes of technicians’ face-to-face time) together with 99215 (Office or other outpatient visit) unless you append a modifier.

How do you figure out if Medicaid doesn’t reimburse a code or only reimburses a code if you use an appropriate NCCI PTP-associated modifier?

In other words, you also may need to know when a code appears as a Column Two code.

To decide when our example code 99215 is the non-reimbursable code of a PTP code pair, we open an edit files link and use the Filter data button to search for 99215 in the Column Two column.

If you filter for 99215 in Column Two, you’ll see that Medicaid doesn’t reimburse 99215 with 99221, Initial hospital care, unless you use the correct modifier.

How do you know when to use an appropriate NCCI PTP-associated modifier?

Providers can append modifiers to HCPCS/CPT codes only if the clinical circumstances and documentation justify it. Providers can’t append a modifier to a HCPCS/CPT code solely to bypass a PTP code pair edit if the clinical circumstances don’t justify its use. If a state Medicaid program imposes restrictions on a modifier, a provider can only use the modifier to bypass an NCCI PTP code pair edit if the Medicaid program allows it.

In the modifier indicator column in the Medicaid PTP tables, the indicator 0, 1, or 9 shows whether a PTP-associated modifier allows the PTP code pair to bypass the edit.

Correct Coding Modifier Indicators

• 0 (Not Allowed): A modifier indicator of “0” indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit.
• 1 (Allowed): A modifier indicator of “1” indicates that NCCI PTP-associated modifiers may be used to bypass an edit under appropriate circumstances.
• 9 (Not Applicable): A modifier indicator of “9” indicates that the edit has been deleted.

Now that you’ve learned how to use the PTP code pair tables, let’s learn how to search for MUEs.

Looking up Medically Unlikely Edits (MUEs)

An MUE for a HCPCS/CPT code is the maximum UOS that a provider would report under most circumstances for a single patient on a single date of service.

Not all HCPCS/CPT codes have an MUE.

CMS develops MUEs based on:

• HCPCS/CPT code descriptors
• Coding instructions
• Anatomic considerations
• Established CMS policies
• Nature of service or procedure
• Nature of analyte
• Nature of equipment
• Prescribing information
• Clinical judgment

MUE values aren’t utilization or coverage guidelines and don’t represent UOS that providers may report without concern about medical review. Providers can only report services that are medically reasonable and necessary. A denial of services due to an MUE is a coding denial, not a coverage or medical necessity denial.

Return to the Medicaid NCCI Edit Files webpage and choose an NCCI MUE link under the Complete Medicaid NCCI Edit Files heading.

Figure 5 shows the unfiltered MUE table on the NCCI Medically Unlikely Edits (MUEs) dataset webpage for Practitioner Services as of the date of writing of this publication.

1. Quarter Begin Date: The first date the quarterly edit file is effective
2. Category: The category of service
3. HCPCS/CPT Code
4. MUE Value: MUEs define for each HCPCS/CPT code the maximum units of service that a provider would report under most circumstances for a single patient on a single date of service
5. MUE Rationale: Shows the rationale for each MUE value

Manuals

The Medicaid NCCI Reference Documents webpage shown in Figure 6 includes links to the Medicaid NCCI Policy Manual, Medicaid NCCI TGM, and Medicaid NCCI Correspondence Language Manual. You also can get to the manuals by choosing Reference Documents in the menu on the left side of The National Correct Coding Initiative in Medicaid webpage.

The Medicaid NCCI Reference Documents webpage also includes links to Proper Use of Modifiers 59 & -X{EPSU}, NCCI MUE and PTP Edit Savings Guidance for State Medicaid Agencies, reports to Congress, and an archive of past manuals.

Medicaid NCCI Policy Manual

The Medicaid NCCI Reference Documents webpage has a link to the Medicaid NCCI Policy Manual.

The manual’s Introduction and Chapter 1 are excellent resources for basic information about proper coding practices and the development of NCCI edits. The Introduction includes general NCCI background information. Chapter 1, General Correct Coding Policies, addresses general coding principles, issues, and policies. Chapters dealing with specific groups of HCPCS/CPT codes further address many of these principles, issues, and policies.

Carefully review chapters that apply to code ranges you bill. These chapters include detailed information about correct coding and NCCI-associated modifiers for separately reportable services.

Medicaid NCCI Technical Guidance Manual (TGM)

The NCCI program updates the Medicaid NCCI TGM annually. The TGM offers technical help for states on correctly and completely implementing NCCI edits.

Medicaid NCCI Correspondence Language Manual

The Medicaid NCCI Correspondence Language Manual offers guidance to providers when a fiscal agent or SMA refers to a CLEID.

Filtering the NCCI Data Tables

As we discussed earlier in the educational tool, you can access the Medicaid NCCI PTP and MUE tables from the Medicaid NCCI Edit Files webpage. Scroll down the webpage to find links to the most recently updated tables.

The filtering and download functions on the PTP and MUE tables operate in the same way. We will use an NCCI PTP table for Practitioner Services updated on 04/01/2022 for our filtering examples.

1. Click the link of the PTP table you want to review. The table’s webpage will appear as shown in Figure 7.

2. Click the Filter data button under the Create a filter heading as shown in Figure 8.

An Add filters column will appear on the right side of the page as shown in Figure 9.

Let’s take a closer look at the Add filters menu options. Figure 10 shows the filter options that appear on the right side of the page when you choose the Filter data button on the Dataset page.

You can filter by:

• Column name (Quarter Begin Date, Category, Column One, Column Two, Effective Date, Deletion Date, Modifier Indicator, and PTP Edit Rationale)
• Wording (This depends on the column name you choose.)
• Filter value (This depends on the column name and verb content you choose.)

To add more filter parameters, click the Add another filter link as shown in Figure 11.

Click the Update table button at the bottom of the Add filters column when you have completed your filter choices as shown in Figure 12.

You can adjust spacing between rows in your table as shown in Figure 13 using the Display density links:

• Tight
• Normal
• Expanded

To download data as an CSV/TEXT file, click the Download filtered view (CSV) link under the Access heading as shown in Figure 14 below. The browser will start working to download the file. Once the downloading progress bar stops, drag the file into a folder. Right click on the CSV file name and select Open with. Then click on the Notepad.

Figure 15 shows the filtering function using 2 conditions: Column One shows our example code 99215, and the Modifier Indicator column shows modifier 1. Figure 16 shows the results of that filter search.

Resources

• Medicaid NCCI Datasets
• Medicaid.gov
• National Correct Coding Initiative Technical Guidance Manual for Medicaid Services
• Medicaid NCCI Edit Files
• The National Correct Coding Initiative in Medicaid
• National Correct Coding Initiative Edits in Medicare
• National Correct Coding Initiative Correspondence Language Manual for Medicaid Services

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