With the upcoming MMIS upgrade, WV Medicaid will be editing claims based on NCCI methodologies. An FAQ is posted below with some commonly asked questions. The CMS website was used to formulate responses and can also be a useful source of reference for more information on NCCI editing.
Additional information can be obtained by accessing the following website:
What are NCCI Edits?
NCCI edits are defined as edits applied to services performed by the same provider for the same beneficiary on the same date of service.
They consist of two types of edits:
NCCI procedure-to-procedure edits that define pairs of HCPCS/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons; and Medically Unlikely Edits (MUEs), or 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.
When did NCCI editing come about?
NCCI is a CMS program that consists of coding policies and edits. This program was originally implemented to ensure accurate coding and reporting of services by physicians. The NCCI procedure-to-procedure edits have been successfully used by the Medicare program since the mid-1990s with the adoption of MUE editing in 2007.
What are the five NCCI methodologies required for implementation in State Medicaid programs?
NCCI procedure to procedure edits for practitioner and ambulatory surgical center (ASC) services.
NCCI procedure to procedure edits for outpatient hospital services.
MUE units of service edits for practitioner and ASC services.
MUE units of service edits for outpatient hospital services.
MUE units of service edits for supplier claims for durable medical equipment.
Are Medicare crossover claims exempt from NCCI and MUE editing?
If the claim received contains a Medicare payment it would be exempt from NCCI and MUE editing, as Medicaid would be considered the secondary carrier and the responsibility for editing would fall under Medicare‟s processing rules.
When are NCCI edits updated?
Revisions to the NCCI edits are published quarterly in January, April, July and October of each year. States are mandated to implement all revisions as published by CMS. Providers should check the current list of edits when billing services that are not separately payable or exceed MUE limits. If billing does not comply with the NCCI edits in place at the time the claim line in question will be denied.
Am I allowed to bill an NCCI modifier so that I can be reimbursed for both procedures?
Program Integrity will be monitoring the use of specific modifiers and randomly and routinely requesting records to support their use to ensure payments made are accurate and appropriate. Any payments made through improper use of modifiers solely to bypass NCCI edits or not meeting clinical requirements will be recovered.
What providers will be impacted by NCCI
As CCI edit mandates are continually updated all providers may ultimately be affected. It is imperative that each provider remain current on CCI editing requirements which can be found at the following link: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-