The Medicaid National Correct Coding Initiative
The Medicaid National Correct Coding Initiative (NCCI) program allows for states to reduce improper payments in Medicaid and Children's Health Insurance Program (CHIP).
The Medicaid NCCI methodologies must be applied to Medicaid fee-for-service (FFS) claims which are submitted with and reimbursed on the basis of Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes. This includes claims reimbursed on an FFS basis in state Medicaid Primary Care Case Management (PCCM) managed care programs. Application of NCCI methodologies to FFS claims processed by limited benefit plans or Managed Care Organizations (MCOs) is desirable but optional. The Medicaid NCCI program has significant differences from the Medicare NCCI program.
Examples of differences include:
- Some Medicare NCCI edits are not present in the Medicaid NCCI program, while others are present but differ in some way from the Medicare NCCI edits.
- Medicaid NCCI PTP edits for DME are unique to the Medicaid program (i.e., the Medicare NCCI program does not have DME NCCI PTP edits).
- The Medicaid NCCI program has certain edits unique to the Medicaid NCCI program (e.g., edits for codes that are noncovered or otherwise not separately payable by the Medicare program).
- Unlike Medicare, for which most MUE edits are applied based on the date of service, Medicaid MUEs are applied separately to each line of a claim.
States must download the NCCI edit files available on a secure portal (RISSNET) rather than using the publicly available files. States must ensure that they or their vendor uses the appropriate Medicaid NCCI edits to adjudicate Medicaid claims.
Types of Medicaid NCCI Edits
NCCI for Medicaid contains two types of edits:
- Procedure-to-Procedure (PTP) edits 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 PTP edits prevent improper payments when incorrect code combinations are reported.
- Medically Unlikely Edits (MUEs) define, the maximum Units of Service (UOS) reported for a HCPCS/CPT code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.
- Posted Sep 14, 2023 Replacement Files (4th quarter of 2023) – CMS issued replacement files for NCCI Procedure to Procedure (PTP) edits for the October 1, 2023 files (PRA and OPH). Effective July 1, 2023, CMS implemented NCCI PTP edits between Column One codes 80305, 80306, and 80307 for presumptive test(s), and Column Two codes G0480 – G0483, and G0659 for definitive test(s). CMS will withdraw these edits retroactive to July 1, 2023 in a replacement file for the 4th quarter of 2023. CMS posted a replacement file on the NCCI PTP webpage.
- Effective July 1, 2023, CMS implemented bypassable NCCI PTP edits between Column One codes 22630, 22632, 22633 and 22634, and Column Two codes 63052 and 63053. CMS will delete these edits in the October 1, 2023 edit files. Providers/suppliers may choose to hold claims until implementation of the October 1, 2023 edit files.
- CMS issued replacement files with the following changes:
- Posted Dec. 7, 2022: Replacement Files (1st quarter 2023) - CMS issued replacement files for NCCI Procedure to Procedure (PTP) edits and updated for the January 1, 2023 files (PRA and OPH).
Section 6507 of the Affordable Care Act requires states to use “compatible” NCCI methodologies when 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 by emailing the NCCI Contractor at NCCIPTPMUE@cms.hhs.gov.
States are no longer required to send NCCI deactivation requests to CMS Regional Offices.
NCCI Contact Information
The NCCI program may address general questions and concerns about the NCCI program and edits. You must submit claim-specific inquiries to your State Medicaid Agency. This includes appeals of NCCI-related denials; see Submitting an Appeal below.
The NCCI program cannot answer questions outside of our scope, or questions about other CMS programs or about other payors. For example, we cannot answer questions about local coverage determinations, changes to code descriptors or status indicators, or modifiers not associated with NCCI.
The NCCI webpages include edit files, the Medicare NCCI Policy Manual, FAQs, and additional information. CMS does not provide a look-up service or a clean claims tool.
You may submit inquiries about the NCCI program, including those related to NCCI (PTP, MUE, and Add-On) edits, in writing via email to NCCIPTPMUE@cms.hhs.gov.
**NOTE** Don’t submit any Personally Identifiable Information (PII) or Protected Health Information (PHI).
Submitting an Appeal
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 a way to resubmit claims or provide additional documentation to support their claims.
You must submit appeals to your responsible State Medicaid Agency, not the NCCI contractor. For CMS policy on provider appeals of denials of payment for HCPCS / CPT codes billed in Medicaid claims due to the Medicaid NCCI methodologies, see State Medicaid Director Letter #11-003 (PDF). The NCCI contractor cannot process specific claim appeals and cannot forward appeal submissions to the appropriate appeals contractor.
Helpful Educational Materials
- How To Use NCCI Tools (PDF): Learn to navigate the CMS Medicaid NCCI webpages and work with Medicaid procedure-to-procedure edits and medically unlikely edits. Find information on how to access and use the Medicaid NCCI files available to the general public.
- CMS no longer participates in the National Medicaid Enterprise Hub (NMEH) calls. However, states can continue to obtain information on the NCCI program via our website and the NCCI Mailbox at NCCIPTPMUE@cms.hhs.gov. As an alternative, states can contact their State Program Integrity Directors to obtain the Fraud, Waste, and Abuse (FWA) Technical Advisory Group (TAG) call information. Please note that only state staff (no contractors) may attend FWA TAG calls.
- Proper Use of Modifiers 59, XE, XP, XS, and XU (PDF) - Posted June 8, 2021
- NCCI MUE and PTP Edit Savings Guidance for State Medicaid Agencies (PDF) - November 2019