On January 1, 2013 the Centers for Medicare and Medicaid Services (CMS) released the latest version of the National Correct Coding Initiative (NCCI) edits. The NCCI edits are code edits published by both Medicaid and Medicare to support correct coding and claims adjudication. Included in the new Medicaid and Medicare edits were edits on all Current Procedural Terminology (CPT®) evaluation and management (E/M) services that disallow patient with immunization administration codes without the proper modifier. The modifier indicator for all these edits is a "1," meaning that with proper modifier placement, the edit can be overridden.Actions to Date
The Academy is urgently working with National Correct Coding Solutions - the CMS contractor for NCCI edits - to have the edits suspended on all preventive medicine service codes (99381-99385 and 99391-99395) with all immunization administration codes (90460 and 90461, 90471-90474).
- January 28, 2013 the AAP sent an email to the membership regarding this problem and linked to a letter from the AAP to CMS.
- February 1, 2013 the AAP sent an Advocacy Flash alerting chapters to the CMS decision to allow state Medicaid programs to deactivate this edit at state option, retroactive to January 1, 2013.
- February 8, 2013 the AAP sent an Advocacy Flash to Chapters urging them to advocate that State Medicaid Programs deactivate the NCCI edit. February 8, 2013 the AAP sent an email to the membership updating them on this problem.
- March 2013, the AAP collected data on how this is impacting practices and shared results with CMS.
- March 8, 2013 The AAP receives an announcement from CMS to be posted to the MII Messenger. “CMS is extending the option for state Medicaid agencies to voluntarily deactivate without prior CMS approval Medicaid NCCI PTP edits for designated preventive-medicine, evaluation-and-management CPT codes until the end of 2013.” According to the announcement “As a result of comments received from the American Academy of Pediatrics and some state Medicaid agencies, CMS has decided to permit state Medicaid agencies to deactivate these edits in their Medicaid Management Information Systems through the end of 2013, if they choose to do so, retroactive to January 1, 2013.”
- March 13, 2013 The AAP sent an Advocacy Flash urging Chapters to seek Medicaid NCCI edit deactivation for entire 2013 calender year. Table 1 identifies the edits in question. Please note that this only pertains to all immunization administration codes and preventive medicine services.
- April 18, 2013 The AAP met again by phone with CMS to once again advocate for the deactivate of the NCCI edits on immunization administration codes and preventive medicine services. While CMS still plans to keep the edit in place, they did share with the AAP results from a State Medicaid survey about which states please to deactivate the edit, keep the edit or have no plan in place currently (or did not respond). The results show that 12 states have deactivated the edit or plan to, 28 states do not plan to deactivate and 11 states either did not respond or were unclear as to their plan.
- December 5, 2013, a joint letter to the Honorable Kathleen Sebelius was sent from the AAP and thirteen other organizations, all who are members of the Immunization Alliance.
We understand this is an administrative burden for you and your staff. The AAP is working diligently to unlock this change and will forward additional information on this issue as it becomes available.
The AAP offers education resources for Medicaid NCCI edits:
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