Medicaid NCCI FAQ Library
Medicaid NCCI FAQ Library
1. What is the National Correct Coding Initiative (NCCI)?
NCCI is a CMS program that consists of coding policies and edits. Providers report procedures or 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 or services performed by the same provider for the same beneficiary on the same date of service.
NCCI was originally implemented for the Medicare program in Jan. 1996 to ensure accurate coding and reporting of services by physicians. The Affordable Care Act of 2010 required CMS to notify states by Sep. 1, 2010, of the NCCI methodologies that were compatible with Medicaid. The State Medicaid Director Letter (PDF) notified states that all five Medicare NCCI methodologies were compatible with Medicaid. The Affordable Care Act required state Medicaid programs to incorporate compatible NCCI methodologies in their systems for processing Medicaid claims by Oct. 1, 2010.
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.
2. What guidance did State Medicaid Director Letter (SMDL) #10-017 implement?
SMDL #10-017 (PDF), issued on Sep. 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), collectively referred to as the “Affordable Care Act,” signed into law on March 23, 2010. In this SMDL, CMS provided guidance and established policy in support of Section 6507 implementation, “Mandatory State Use of National Correct Coding Initiative (NCCI),” in Subtitle F, “Additional Medicaid Program Integrity Provisions,” Title VI, “Transparency and Program Integrity.”
Support for States
1. What does Section 6507 of the Affordable Care Act require of state Medicaid programs regarding the National Correct Coding Initiative (NCCI)?
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 amends section 1903(r) of the Social Security Act (the Act). Section 1903(r)(4) of the Act, as amended, required that CMS notify states by Sep. 1, 2010, of the NCCI methodologies that are “compatible” with claims filed with Medicaid, to promote correct coding and to control improper coding leading to inappropriate payment of claims under Medicaid.
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 had been established for Medicare. In addition, 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, required states to incorporate compatible methodologies of the NCCI administered by the Secretary and other such methodologies as the Secretary identifies by Oct. 1, 2010, for Medicaid claims filed on or after Oct. 1, 2010.
CMS was required to submit a report to Congress by March 1, 2011, that included the Sep. 1, 2010, notice to states and an analysis supporting these methodologies.
2. What does CMS provide to states to implement NCCI in Medicaid?
Approximately 45 days before the beginning of a new calendar quarter, CMS provides the Medicaid NCCI edit files for states to download. These files are available for states on a secure portal (RISSNET). The files are available in three file formats: fixed-width American Standard Code for Information Interchange (ASCII) text, tab-delimited ASCII text, and Excel. 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 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 and are posted in Excel and tab-delimited ASCII text formats.
- NCCI Policy Manual for Medicaid Services – This manual clarifies the policies on which the Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs) are based and will assist staff 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 - Read the annual reports of CMS's efforts, through the Center for Program Integrity, to combat fraud, waste and abuse of the Medicare, Medicaid and Marketplace programs.
- Medicaid NCCI Technical Guidance Manual - This document provides information for state Medicaid agencies and fiscal agents about NCCI policies.
3. What funding is available to states to implement section 6507 of the Affordable Care Act?
Section 1903(r) of the Social Security Act (the Act), as amended by section 6507 of the Affordable Care Act, describes the functionality of a state’s Medicaid Enterprise System (MES) (previously known as the Medicaid Management Information System (MMIS)), a state’s information retrieval and automated claims-payment processing system. With the enactment of this section, a state MES must include Medicaid NCCI methodologies as part of their functionality.
Section 1903(a)(3) of the Act provides CMS with the authority to provide enhanced federal financial participation (FFP) to states for the design, development, installation, and maintenance of the state's MMIS. Thus, in considering revisions to a state’s MMIS, CMS is authorized to provide 90 percent FFP to states to incorporate Medicaid NCCI methodologies into the state’s MMIS.
CMS uses the current Advanced Planning Document (APD) process when states request MMIS funding. States should work with their respective CMS Regional Offices to request enhanced FFP through submission of a Medicaid NCCI APD.
Published Edit Files
1. Where can I find additional guidance on National Correct Coding Initiative (NCCI) edits in Medicaid?
How to Use the Medicaid National Correct Coding Initiative (NCCI) Tools (PDF)
Learn to navigate the CMS Medicaid NCCI web pages and how to work with Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs). Find information on how to access and use the Medicaid NCCI files available to the general public. Note: The Medicare NCCI program has significant differences from the Medicaid NCCI program.
2. What are the differences between the public Medicaid NCCI edit files and the Medicaid NCCI edit files that are posted on the secure Regional Information Sharing System (RISSNET) portal?
Access to the complete quarterly Medicaid NCCI edit files that are posted on the secure RISSNET portal is limited to each State Medicaid Agency (SMA). 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 web page (i.e. MUEs) that are no longer in effect, their effective date and deletion date, the effective date of current MUEs, and the Correspondence Language Example Identifiers (CLEID) for PTP edits and MUEs).
3. Why can’t states use the public Medicaid NCCI edit files to process their Medicaid claims?
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 web pages 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.
4. Can State Medicaid Agencies share NCCI data files obtained through the secure RISSNET portal with vendors or other contracted parties?
A state Medicaid agency may share the quarterly state Medicaid NCCI edit files posted on the secure RISSNET portal with the contracted fiscal agent that processes its Fee-for-Service (FFS) claims if appropriate confidentiality agreements are in place. A state Medicaid agency may also share the quarterly state Medicaid NCCI edit files 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 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 doesn’t need to 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.
5. Are all Medicaid NCCI PTP edits and MUEs published and available to states and providers on the CMS website?
All currently active and previously active Medicaid PTP edits are published for use by the general public and interested parties.
MUEs that are active for dates of service in the current quarter are published for use by the general public and interested parties; previous MUEs with deletion dates prior to the current quarter are not included.
States and providers must be aware that there are several differences between Medicaid and Medicare NCCI edits. For example:
- Medicare has some non-published or confidential MUEs. However, there are currently no confidential or non-published edits in the Medicaid NCCI program.
- MUEs for the same code may have different values in the Medicare and Medicaid NCCI programs.
- The Medicaid NCCI program has PTP edits for durable medical equipment; the Medicare NCCI program does not.
- The Medicaid NCCI program has PTP edits and MUEs for codes that are not covered or not separately payable by the Medicare program.
It’s important that providers and others use the correct website to obtain the Medicaid PTP edit and MUE files. Providers and others sometimes access the Medicare NCCI section of the CMS.gov website to obtain the NCCI edit files, rather than the Medicaid NCCI web pages. It is important to note that there are two separate NCCI pages, one for each program. Conducting a general search of “NCCI” or “National Correct Coding Initiative” directly from the CMS.gov website may take the user to the Medicare page, not the Medicaid page. Providers and others should go to the Medicaid NCCI web page to obtain Medicaid-related NCCI information and edit files.
States must download the NCCI edit files that are available on the Medicaid Integrity Institute (MII) website using a secure portal (RISSNET) rather than using the publicly available files from the Medicaid NCCI website. States must ensure that they or their vendor are using the appropriate Medicaid NCCI edits to adjudicate Medicaid claims.
NCCI Edits and Methodologies
1. What are the National Correct Coding Initiative (NCCI) methodologies for the Medicaid program?
The Medicaid NCCI program consists of six methodologies:
- Procedure-to-Procedure (PTP) edits for practitioner and ambulatory surgical center (ASC) services
- PTP edits for outpatient services in hospitals (including emergency department, observation, and hospital laboratory services)
- PTP edits for durable medical equipment
- Medically Unlikely Edits (MUEs) for practitioner and ASC services
- MUEs for outpatient services in hospitals
- 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.
Each of the Medicaid NCCI methodologies has four components:
- A set of edits
- Definitions of types of claims subject to the edits: Information on claim adjudication rules for applying Medicaid NCCI methodologies when processing state Medicaid claims is contained in appendices B and C of the Medicaid NCCI Technical Guidance Manual.
- A set of claim adjudication rules for applying the edits
- Information on claims denials based on the NCCI edits, found in the State Medicaid Director Letter #11-003 (PDF)
The State Medicaid Director Letter states the CMS policy on provider appeals of payments of Medicaid claims denied due to the Medicaid NCCI edits.
2. Will CMS develop new NCCI methodologies that were not identified in SMDL #10-017?
CMS fully anticipates, and will continue to evaluate the application of, emerging NCCI methodologies and/or edits to improve coding initiatives and achieve additional savings. Since SMDL #10-017, CMS added PTP edits for DME, which were implemented in Oct. 2012. If newer methodologies are developed, CMS will update states accordingly.
3. What is an NCCI edit and how does it differ from an NCCI methodology?
NCCI edits are one component of the NCCI methodologies. The 6 Medicaid NCCI methodologies contain approximately 3 million PTP edits and 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 or services performed on beneficiaries utilizing HCPCS/CPT codes. These codes are submitted on claim forms to fiscal agents for payment.
The NCCI methodologies contain two types of edits:
- NCCI 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.
- MUEs define, for many HCPCS/CPT codes, the maximum units of service (UOS) that are billable by the same provider, for the same beneficiary, on the same date of service under most circumstances. 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.
4. If a provider receives a denial that is attributed to an NCCI PTP edit or MUEs, can the provider verify the edit on the Medicaid NCCI web page on the Medicaid.gov website?
As discussed above, all currently active Medicaid PTP edits and MUEs are published on the Medicaid NCCI web page, i.e., all edits that are applicable to claims with dates of service in the current calendar quarter:
- The PTP edit files that are posted on the Medicaid NCCI web page also contain historical information; i.e., they contain the effective date of every edit and the deletion date of prior edits. This information can be used to verify whether a particular PTP edit was valid on the date of service (DOS) of the claim in question and whether use of a PTP-associated modifier would allow the claim to bypass the edit.
- The MUE files on the Medicaid NCCI web page identify the edits that are applicable to claims processed in the current quarter and with dates of service in the current quarter. They do not contain historical information; i.e., they do not contain the effective dates of current edits, nor do they include prior edits that have been deleted or revised. However, that information is available to the states in the files that a state downloads from the MII website using a secure portal (RISSNET). Providers who want to verify whether there was an MUE and what the value was for that MUE on a DOS prior to the current quarter would need to contact the state.
As discussed above, it’s imperative that providers access the Medicaid NCCI edit files on the Medicaid NCCI web page and not the Medicare NCCI edit files, as there are significant differences between the two sets of files.
If providers are reporting NCCI-related denials that are not appearing in the Medicaid NCCI edit files, the state should contact their vendor or check their system to determine the origin of the edit. If the edit is not part of the Medicaid NCCI PTP editor MUE file sets, the denial may not be attributed to NCCI. States have the flexibility to create other PTP edits or units-of-service edits but should be using state-specific denial messages for these edits, not NCCI-related denial messages.
5. If two different physicians in my clinic perform the same procedure or service on the same day for the same beneficiary, will both services be paid?
NCCI MUEs for HCPCS/CPT codes apply to services reported by the same provider/supplier for the same beneficiary on the same date of service.
The NCCI program contractor provides general information to the public regarding the NCCI program and edits. However, we do not provide specific billing or coding advice to providers / suppliers, and we do not deal with payment issues. Questions regarding specific claims should be addressed to your claims processing contractor (e.g., your State Medicaid Agency).
6. Can denials resulting from NCCI edits be appealed?
A provider with an NCCI-related claim denial is subject to the standard state appeals or claim resubmission process(es). 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 provide advance notice regarding potential errors associated with claim denials, including those generated by NCCI edits, and that providers have an avenue to resubmit claims or provide additional documentation to support their claims.
7. Upon analysis by states, what if one or more edits are found that are necessary to improve correct coding within a state’s Medicaid program, but are not currently included within an NCCI methodology?
States are free to apply their own edits, in addition to the Medicaid NCCI edits, that meet the statute’s intent to improve correct coding within the states’ Medicaid programs. However, these state-specific edits should not be characterized as NCCI edits. If such state edits result in additional savings to a state’s Medicaid program by promoting correct coding and reducing the error rate for claims payments, the state should recommend that CMS add these edits to one or more sets of Medicaid NCCI edits.
8. Upon analysis by states, what if an edit is found to conflict with a state law or regulation, but is currently included within an NCCI methodology?
CMS allows states to consider edits on an individual, state-by-state basis. If a state determines that an edit in the Medicaid NCCI methodologies conflicts with one or more state laws, regulations, administrative rules, or payment policies, the state can request permission from CMS to deactivate the conflicting edit. States are not afforded the flexibility to deactivate edits after March 31, 2011, due to a lack of operational readiness.
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 mailbox at NCCIPTPMUE@cms.hhs.gov. The request must include sufficient primary source documentation of the conflicting state law, regulation, administrative rule, or payment policy. States are no longer required to send NCCI deactivation requests to the CMS Regional Offices.
Billing and Coding Advice
1. How do I obtain billing and coding advice from the National Correct Coding Initiative (NCCI) Program?
The NCCI program contractor provides general information to the public regarding the NCCI program and edits. However, we do not provide specific billing or coding advice to providers / suppliers. Questions regarding specific claims should be addressed to your claims processing contractor (State Medicaid Agency). Providers / suppliers may also find it helpful to contact their national healthcare organization or the National Healthcare Organization (NHO) whose members commonly perform the procedure.
2. What can I do about other commercial payers who deny payment citing NCCI edits?
Other government and private insurers may voluntarily choose to adopt Medicare's NCCI methodologies. The application of Medicare’s NCCI methodologies, and thereby the application of Medicare payment policies and rules, to claims other than Medicare Part B claims may result in denials by other plans. Plans that voluntarily choose to adopt Medicare's NCCI methodologies should review their edits and consider deactivating individual edits that conflict with their own benefit and coverage determinations. If you have questions or concerns regarding this process, please contact your payer directly.