NCCI Requirements Become Mandatory for Medicaid
The Centers for Medicare & Medicaid (CMS) developed the National Correct Coding Initiative (NCCI) to promote appropriate coding, and control improper coding that might lead to inappropriate payment of claims. Implemented in 1996, NCCI edits help identify incorrect code combinations.1
Medicare uses NCCI edits as part of the prepayment claims review process. The prepayment review process helps ensure that Medicare pays the claim correctly the first time; however, these reviews are challenging due to the volume of claims. Overall, less than 1 percent of Medicare's claims are subject to a medical record review by trained personnel.2 All Medicare claims are subject to NCCI edits.
NCCI edits consist of two types of edits:3
NCCI procedure-to-procedure edits that 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
Medically Unlikely Edits (MUE), units-of-service edits, that define for each HCPCS / CPT code the number of units of service beyond which the reported number of units of service is unlikely to be correct
There are two sets of NCCI edits:1
The NCCI Edits - Physicians" set applies to providers who bill Part B services on the CMS-1500 claim form
The "NCCI Edits - Hospital Outpatient PPS" set applies to providers who bill Part B services to Part A on the UB-04 claim form (i.e., hospitals who bill outpatient services paid under the Outpatient Prospective Payment System (OPPS), Critical Access Hospitals (CAHs), Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs) and Outpatient Rehabilitation Facilities (ORFs)).
The NCCI contains two tables of edits:1
The Column One/Column Two Correct Coding Edits table
Mutually Exclusive Edits table include code pairs that should not be reported together
*Both tables indicate if the proper use of a modifier will allow separate payment when billed with the secondary code.
Example of NCCI evaluation and management edits for physicians in the column 1/column 2 table format:3
Column 1/Column 2 Edits
Column 1
Column 2
* = In
existence
prior to 1996
Effective Date
Deletion
Date* =
no data
Modifier
0 = not allowed
1 = allowed
9 = not applicable
96401
99211
20060101
*
0
96401
99212
20060101
*
1
96401
99213
20060101
*
1
96401
99214
20060101
*
1
96401
99215
20060101
*
1
Revisions to the NCCI edits are published quarterly in January, April, July and October each year. Providers should check the current list of edits when billing services that are not separately payable except under certain circumstances.
In addition to Medicare, the Patient Protection and Affordable Care Act (PPACA) required state Medicaid programs to incorporate NCCI methodologies into Medicaid claims processing systems by October 1, 2010.3 Some state Medicaid programs may already have adopted the NCCI edits, but the law requires all states to use the edits.
In a letter issued September 1, 2010 to all State Medicaid Directors, CMS outlined the 3 main actions taking place required by the Act, which were:4
Adopting NCCI methodologies that are "compatible" with claims filed with Medicaid to promote correct coding and control improper coding leading to inappropriate payment of claims under Medicaid.
Reviewing NCCI methodologies (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) that should be incorporated for claims filed with Medicaid for which no national correct coding methodology has been established for Medicare.
How States can incorporate these methodologies for claims filed under Medicaid.
CMS developed a separate policy manual for Medicaid services entitled, The National Correct Coding Initiative Policy Manual for Medicaid Services, as well as the NCCI Correspondence Language Manual on the Medicaid NCCI webpage on the CMS Web site. 3
Medicaid providers are encouraged to adopt the edits by reading and implementing the recommended changes issued by CMS.
References:
1 The Centers for Medicare & Medicaid Services Web site. Accessed March 1, 2011. Available at https://www.cms.gov/nationalcorrectcodinited/.
2 United States Accountability Office. Medicare Fraud Waste and Abuse, Challenges and Strategies for Preventing Improper Payments. June 15, 2010. Accessed March 1, 2011. Available at http://www.gao.gov/new.items/d10844t.pdf.
3 The Centers for Medicare & Medicaid Services. National Correct Coding Initiatives Edits. Details for Evaluation and Management Services. Accessed March 1, 2011. Available at https://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage
4 The Centers for Medicare & Medicaid Services. NCCI letter to State Medicaid Directors [SMD10017], September 1, 2010. Accessed March 1, 2011. Available at http://www.cms.gov/smdl/downloads/SMD10017.pdf.
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