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Medicaid Implementation of National Correct Coding Initiative (NCCI) Edits

Association Management Plus, LLC (AMPlus) recently met with Anthony Pelezo, M.D., Medicaid Medical Director, and discussed the upcoming implementation of the NCCI for Medicaid claims. Additionally, AMPlus participated in the NCCI virtual seminar conducted by HP on October 8, 2010. Some important information and clarifications regarding the implementation were obtained and are listed below.

  • The application of NCCI edits will be handled by an external vendor, McKesson. After claims are received by HP the claim data will be transmitted by HP to McKesson. McKesson will then run the claims through NCCI files and apply any bundling edits to the claim based on the Column I/Column II, Mutually Exclusive, and/or Medically Unlikely Edits (MUEs). If applicable, McKesson will apply edit overrides, based on the presence of modifiers. The claim data will then be transmitted back to HP to finish the adjudication cycle. This process will not affect the time-frames in which claims are processed, other edits applied by HP related to Medical Policy and coverage, or the information provided on the Remittance Advice notifying a provider of all errors on a particular claim. 
  • The NCCI Medicaid edits were scheduled to be implemented on October 28, 2010. This date has been delayed. The new implementation date has not yet been announced. The delay was caused by some unforeseen technical difficulties with transmitting claim data to McKesson. Monitor the IHCP website for information about the revised implementation date.
  • The NCCI edits were to be effective for all claims on or after October 1, 2010. However, CMS did not specify whether the October 1st date was to be applied to claims received or claims with dates of service. This has now been clarified and will apply to claims with dates of service on or after October 1, 2010.
  • Once the edits are turned on, all claims with dates of service on or after October 1, 2010, that have already been processed will have to be reprocessed by HP to apply the NCCI edits. This may result in retroactive NCCI denials for bundling, excessive units of service, or medically unlikely services. When HP reprocesses the claims, any overpayments as a result of the NCCI bundling will be recouped via the accounts receivable process. HP will notify providers of the mass reprocessing date(s) once they have been established.
  • Several standard NCCI edits have been identified as conflicting with existing Indiana Medicaid policies and billing instructions. Indiana Medicaid has requested permission from CMS to deactivate these particular edits. As new conflicts are identified, additional requests for permission to deactivate edits will be submitted by Medicaid. It should be noted, Medicaid must request and receive permission from CMS before it may deactivate any NCCI edit. At this time, the following conflicts have been identified and permission has been requested and granted to deactivate the edits (this list is not all inclusive):
    • Indiana Medicaid policy directs providers to unbundle OB services and to bill lab services separately from the OB services. NCCI edits related to 59425 and 59426 billed with -U1, -U2, and -U3 modifiers and/or when billed with certain lab services identified in BT201036 have been deactivated.
    • MUE edits regarding limitations for blood glucose testor reagent strips, per 50 strips (A4253). MUE limitation is 2 units; Indiana Medicaid policy allows 4 units (200 test strips). The MUE limitation has been deactivated.
    • MUE edits regarding the limitation on lancets, per box (A4259). The MUE edit allows 1 unit; Indiana Medicaid policy allows 2 units per month. The MUE limitation has been deactivated.
  • If a claim “hits” an MUE edit for excessive units of service, the detail line will be denied in its entirety, the system will not cut back the reimbursement to the number of allowed units. The provider will have to correct and resubmit the claim to be reimbursed.
  • When billing services for a span of dates, the “From” and “To” dates must equal the number of units submitted in the “Units” field or the detail will deny. For example, if the member is seen in the inpatient setting from 10/01/2010 through 10/10/2010 and the physician codes 99231 for each date, the claim may be reported with 10/01/2010 in the “From” field, 10/10/2010 in the “To” field and 10 in the “Units” field. However, if the physician did not see the patient on 10/05/2010, the provider cannot report 10/01/2010 through 10/10/2010 with 9 units. The detail would have to be split into 2 service lines with 10/01/10 through 10/04/2010 and 4 units on one line and 10/06/2010 through 10/10/2010 with 5 units of the second line. When billing span dates, all services must occur within the same calendar month; 10/25/2010 through 11/02/2010 with 9 units would not be allowed.
  • Providers should continue to use modifiers as appropriate when reporting services. If a claim hits an NCCI edit at McKesson, their system will look at the claim to determine if a modifier is present that would justify an override of the edit.
    • CMS has identified that some providers often append modifier -59 to override an edit when another modifier has been or should have been used instead. Providers should not routinely append modifier -59 just to override the edits. Modifier -59 should only be used if NO OTHER modifier is applicable and the services reported represent a different session or encounter, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury or area of injury in extensive injuries.  Note:  a procedure or surgery is not “different” merely because it has a separate CPT code. If the additional procedure or surgery is performed at the same site during the same surgical session or is integral to the primary procedure, even though it is identified by a separate CPT code, it is considered bundled and should not be reported with modifier -59 to force the payment.
    • Modifiers -RT and -LT:  These modifiers should be used when appropriate to identify procedures performed on paired organs. The appropriate use of these modifiers will allow McKesson to override an edit when the claim indicates that the service was performed on different sites, as evidenced by -RT and -LT.
    • Anthony Pelezo, MD, Medicaid Medical Director, has informed AMPlus that appropriate modifier use, particularly with respect to modifiers -25, -57, and -59, will be a very high priority for the new Fraud and Abuse contractor/system that is due to be implemented by January 1, 2011. The new contractor has not yet been announced.  
  • NCCI edits do not apply coverage determinations or policy determinations so implementation of these bundling edits will not change Medicaid covered services or billing instruction. Some providers have expressed concern about consultation codes. As Medicare does not cover consultations there is concern that this will be reflected in the NCCI and claims will be denied. The NCCI file listed on the CMS NCCI Coding Page does not contain any bundling edits for consultation codes. Consultations will continue to covered and will be edited based on existing Medicaid policies for coverage and frequency. 
  • Medicaid NCCI Edit Updates:  The NCCI edits are updated on a quarterly basis. The timing of the first update will be determined based on the date that the edits are actually turned on. Watch your Medicaid publications for additional information about the quarterly updates.
  • Medicaid Managed Care:  The federal requirement to use NCCI editing does not extend or apply to Medicaid managed care entities (MCEs). Therefore, the Indiana Medicaid MCEs are not required to use these edits. However, AMPlus has been informed that both Anthem and MHS have been using NCCI editing for Medicaid claims and the MDwise plans are in the process of implementing NCCI editing for their Medicaid claims. It should be noted that while they state they are using NCCI editing, they obtain their bundling logic from other vendors that may add other proprietary bundling logic or modify the bundling logic to be consistent with their stated policies and reimbursement methods. So, do not assume the editing for each of the MCE and HP will be identical.
  • NCCI Bundling Denial Appeals:  To appeal an NCCI edit (Column I/Column II, ME, or MUE) denial the provider must submit an Administrative Review request within 7 calendar days of the receipt of the denial. To submit an Administrative Review, complete the Indiana Health Coverage Programs Inquiry form located in the Forms section of the IHCP website. You must clearly note: Administrative Review Request on the form, state the reason you disagree with the bundling and include documentation that supports separate payment for the services in question (documentation may include office notes, operative notes, admit/discharge summaries, radiology reports, etc). The form and envelope must be marked: Attn: Health Care Administrative Review Specialist. This process should also be utilized for cases in which bundling edits conflict with established Medicaid policies and billing instructions. The provider should state the policy and how it conflicts with a particular NCCI edit. If Medicaid is in agreement, they will submit a request to CMS to deactivate the edit.
  • NCCI Edit Concerns:  If a provider believes an NCCI edit is generally incorrect or inappropriate (across the board for any payer using the NCCI editing system), he/she should contact Correct Coding Solutions, LLC. CMS has approved these edits for Medicaid use and the IHCP is required to use the edits as created by Correct Coding Solutions, unless the IHCP or a provider can show just cause as to why an edit is inappropriate. Information should be sent to:  National Correct Coding Solutions, LLC, PO Box 907, Carmel, IN  46082-0907, Attn:  Niles Rosen, M.D., Medical Director or Linda Dietz, RHIA, CCS, CCS-P, Coding Specialist.
  • During a previous presentation, Dr. Pelezo stated that the edits have been set up by CMS to promote appropriate coding. Therefore, if a provider submits codes which are considered bundled by the NCCI, Medicaid has been directed to allow payment for the lesser valued service, which is usually the Column I or component code. Providers that do not change inappropriate coding patters will be underpaid and will have to submit a void/replacement (aka, Adjustment) to receive correct reimbursement. Medicaid has requested a waiver from CMS to allow them to pay the higher valued code but at this time permission has not been granted and it is not expected.
  • To obtain a copy of the Power Point presentation from the HP virtual workshop visit www.indianamedicaid.com, click on Provider Education on the menu on the right side of the screen, click on Archived Workshop Presentations on the left side of the screen, and scroll down to National Correct Coding Initiative to open/download/print the presentation. Handout material from various other presentations are included on this page as well.
  • Additional Information: Additional information about NCCI and Medicaid NCCI can be obtained at the following websites:

This entry was posted on Wednesday, November 3rd, 2010 at 3:55 pm and is filed under Indiana Medicaid News. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.

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