CMS NCCI Edits Effective 8/8 for all Louisiana Medicaid Health Plans and Providers
Date: 08/05/22
This statement is to notify you that on Monday, August 8, 2022, all Medicaid health plans will be instituting proper protocol updates to ensure we are fully compliant with the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) editing.
Why is this important?
These NCCI edits could affect some providers’ claims processing and payments. All providers should review the NCCI edits being implemented to understand their applicability and potential impact to their practice.
What are the types of NCCI edits?
The Medicaid NCCI program includes two types of edits: NCCI Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs).
- PTP edits - prevent inappropriate payment of services that should not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code. If a provider reports the 2 codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI PTP-associated modifier is also reported.
- MUE edits - prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service (UOS) under most circumstances reportable by the same provider for the same beneficiary on the same date of service.
What services are affected?
The NCCI PTP edits and MUEs are used to adjudicate provider claims for the following services:
- Practitioner services
- Ambulatory surgical center services
- Outpatient hospital services
- DME, prosthetics, orthotics, and supplies.
Note: The NCCI edits apply regardless of the format in which a claim is submitted (e.g., paper, electronic or web-based submissions).
The Medicaid NCCI PTP edits and MUEs are applied to services performed by the same provider for the same beneficiary on the same date of service.
Medicaid NCCI PTP edits are applied to all services with the same date of service whether the services are submitted on the same or different claims. Medicaid MUEs are applied separately to each line of a claim.
NCCI edits are NOT applied to facility claims for inpatient services.
Where can I find more details?
The above information comes from the revised annual version of the NCCI Technical Guidance Manual for Medicaid effective as of February 28, 2022. Please refer to this document for more information and guidance.
If you have questions…
We are committed to working with impacted providers to resolve any concerns with these requirements.
Please contact your dedicated Provider Network Specialist or Provider Services at 1-866-595-8133 with any questions.