National Correct Coding Initiative Edits - Reminder
Date: 07/19/22
The Centers for Medicare & Medicaid Services (CMS) developed National Correct Coding Initiative (NCCI) editing to promote national correct coding principles and facilitate correct provider reimbursement for all services performed on patients.
LDH has instructed all Medicaid Managed Care Organizations to strictly comply with CMS NCCI guidance without exception. This includes scenarios in which published LDH guidance (in policy manuals, information bulletins, fee schedules, etc.) seems to contradict. For example, MCOs will no longer allow billing of Evaluation & Management visit procedure codes with Vision visit procedure codes on the same-day or subsequent-day; or reimburse Behavioral Health claims billed with multiple units on 1 service line per day (ex – H0015).
Louisiana Healthcare Connections is committed to working with impacted providers as we implement this updated guidance. All providers impacted by this change will be contacted by the Louisiana Healthcare Connections claims team.
How does this currently impact claims?
To ensure accurate coding and reporting of services by providers and suppliers, CMS developed and implemented NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in the Medicare Part B program. The NCCI program was expanded to include Medicaid under section 6507 of the Patient Protection and Affordable Care Act signed into law in March 2010.
The NCCI PTP edits and MUEs are used by state Medicaid agencies or fiscal agents to adjudicate provider claims for the following. NCCI edits are NOT applied to facility claims for inpatient 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).
What are the types of NCCI edits?
The Medicaid NCCI program includes 2 types of edits: NCCI Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs). AOC edits are optional for state Medicaid agencies to use.
- 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.
- AOC edits - consist of a listing of HCPCS and CPT Add-on Codes with their respective primary codes. An Add-on Code is eligible for payment if and only if one of its primary codes is also eligible for payment.
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.
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.
The revised annual version of the NCCI Policy Manual is effective as of January 1, 2022.