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, 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:
- Posted Feb. 3, 2022: Replacement Files (1st quarter of 2022) – CMS issued a third set of replacement files for PTP edits for the Jan. 1, 2022 files.
- Posted Dec. 15, 2021: Replacement Files (1st quarter of 2022) – CMS issued replacement files for PTPs and MUEs for the Jan. 1, 2022 files.
- Posted Oct. 4, 2021: Replacement Files (4th quarter of 2021, V2) – CMS issued replacement files for PTP edits for the Oct. 1, 2021 files.
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 cannot answer questions outside of our scope or about other CMS programs. For example, we cannot answer questions about modifiers not associated with NCCI, Local Coverage Determinations, changes to code descriptors or status indicators. 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 or postal mail to:
National Correct Coding Initiative Contractor
P.O. Box 246
Pittsford, NY 14534
Fax #: 1.585.510.7234
**NOTE** Any submissions made to the NCCI contractor that contain Personally Identifiable Information (PII) or Protected Health Information (PHI) are automatically discarded, regardless of the content, in accordance with federal privacy rules the NCCI Contractor must comply with.
Submitting an Appeal
Appeals must be submitted to your responsible State Medicaid Agency, not the NCCI Contractor. State Medicaid Director Letter #11-003 (PDF) states CMS policy on provider appeals of denials of payment for HCPCS / CPT codes billed in Medicaid claims due to the Medicaid NCCI methodologies. 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.