Medicaid NCCI FAQ

The Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) promotes national correct coding methodologies and reduces improper coding which may result in inappropriate payments of Medicare Part B claims and Medicaid claims. Originally started as a Medicare policy, now state Medicaid plans are required to implement NCCI Edits. The NCCI is a CMS program that consists of coding policies and edits.  Providers report procedures/services performed on beneficiaries utilizing Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT®) codes.  These codes are submitted on claim forms to Fiscal Agents for payment.  NCCI policies and edits address procedures/services performed by the same provider for the same beneficiary on the same date of service.

The Patient Protection and Affordable Care Act (ACA) required state Medicaid programs to incorporate compatible NCCI methodologies in their systems for processing Medicaid claims by October 1, 2010.

NCCI consists of procedure-to-procedure (PTP) edits termed “NCCI edits” and units-of-service (UOS) edits termed Medically Unlikely Edits (MUE). 

1. NCCI procedure-to-procedure (PTP) edits 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. The purpose of the PTP edits is to prevent improper payments when incorrect code combinations are reported. 
2. Medically Unlikely Edits (MUEs) define for each HCPCS/CPT code the maximum units of service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service. 

You can access them here.

NCCI PTP edits define pairs of HCPCS / CPT codes that should not be reported together for a variety of reasons.  These edits consist of a column one code and a column two code.  If both codes are reported, the column one code is eligible for payment and payment for the column two code is denied.  However, each PTP edit has an assigned modifier indicator, which provides information about whether a PTP-associated modifier may be used to bypass the edit, in appropriate circumstances, and allow payment for both the column one and column two codes.  An indicator of “0” means that a modifier cannot be used to bypass the edit.  An indicator of “1” means that a PTP-associated modifier, such as 25, 59, RT, LT, etc., may be used, if appropriate, to bypass the edit.  An indicator of “9” means the edit has been deleted and the modifier indicator is not relevant. 

MUEs define for many HCPCS / CPT codes the maximum allowable number of units of service by the same provider, for the same beneficiary, for the same date of service, on the same claim line.  Reported units of service greater than the MUE value are unlikely to be correct (e.g., a claim for excision of more than one gallbladder).  Billed claim lines with a unit-of-service value greater than the established MUE value for the HCPCS / CPT code are denied payment in their entirety.

The NCCI PTP-associated modifiers are the following: 24, 25, 27, 57, 58, 59, 78, 79, 91, E1 – E4, FA, F1 – F9, FA, LC, LD, LM, LT, RC, RI, RT, T1 – T9, TA. The State’s claims processing system must recognize all of these modifiers and allow the PTP edit to be bypassed, if any of these modifiers is used on either code of the edit pair. Failure to do this will result in incorrect denials of payment that will be falsely attributed to NCCI.

Every quarter new NCCI Edits are added. The 1st quarter begins on January 1; the 2nd quarter begins on April 1; the 3rd quarter begins on July 1; and the 4th quarter begins on October 1 of each year. Be sure to download the NCCI Edit files that are applicable to your practice at the start of every quarter.

Within the NCCI Edit methodology there are 6 distinct methodologies for developing edits. Be sure to download and use the appropriate file for the type of provider you bill for and the type of edit you seek (PTP or MUE). The six methodologies are as follows: 

1. PTP edits for practitioner and ambulatory surgical center (ASC) services. 
2. PTP edits for outpatient hospital services (including emergency department, observation, and hospital laboratory services). 
3. PTP edits for durable medical equipment (as of October 2012). 
4. MUEs for practitioner and ASC services. 
5. MUEs for outpatient hospital services for hospitals. 
6. MUEs for durable medical equipment 

Medicaid NCCI Edit policy states that the modifier may be appended to either the code listed in column 1 or the code listed in column 2 (refer to the edit files) to override the edit. However, CPT guidelines must be considered. For example, there is a PTP edit on an E/M service (eg, code 99213) and a non-E/M service (eg, code 96372). Code 99213 is in column 2 and 96372 is in column 1. In this instance, it will matter where you place the modifier because only modifier 25 can be used in this circumstance, appended to the E/M service (99213). Modifier 59 can only be used when you distinguish between two “non-E/M services” and in this case one of the services is an E/M service. Therefore, you will append to the column 2 code. Typically, that is the rule and the modifier will be placed on the column 2 code. 
 
Report 99213 25 and 96372

Part of the NCCI Edit logic is to review the CPT manual for the coming year to determine if edits should be implemented based on a change in CPT manual instructions. Within CPT a change in guidelines is noted in green font. The decision to implement the edits on all Evaluation and Management (E/M) codes (including preventive medicine services) arose from CMS mistakenly concluding that new guidance was printed within the CPT manual for 2013 when in fact, the guidance deemed “new” by CMS has been present in the CPT manual since 1999. However, CMS saw "green font" (which indicates updates within the CPT manual) but did not review past editions of the CPT manual to determine what within the guidelines had changed. And given that all that had changed was that CPT added in explicit code ranges to go with the guidance already in place, CMS’ assumption that guideline language related to the reporting of the IA codes with the PMS was mistaken. The guidance reads "If a significant and separately identifiable E/M service (eg, new or established patient office or other outpatient services [99201-99215], office or other consultations [99241-99245], emergency department services [99281-99285], preventive medicine services [99381-99429]) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration code." (Note: the only language changed for 2013 is in green, boldface font.)

Contact the AAP. According to CMS, your state Medicaid agency is not compliant with NCCI Edit directives. Please direct all such issues to the AAP Coding & Payment Hotline. 

Private and commercial payers often adopt CMS NCCI Edit logic into their claims systems. It is best that you contact your commercial payers for guidance. Be sure to watch your explanation of benefits (EOBs) very closely and be sure to look into all commercial payer denials or bundling of preventive medicine service codes and immunization administration codes. 
 
The Academy is currently monitoring whether any private or commercial payers may implement these edits. Based on input from AAP members, below is a partial listing of those carriers that reported that they are denying claims for not including modifier 25 when reporting immunization administration and a preventive medicine service E/M code (please note, the list is not comprehensive): Aetna, BCBS AL, BCBS AZ, BCBS DE, BCBS FL, BCBS LA, BCBS MI, Coventry, GHI, MD (Carefirst), NJ (Horizon), PA (Horizon), Medical Mutual of Omaha.

Yes, CMS gave individual state Medicaid agencies the power to deactivate this edit without having to make a formal appeal to CMS. Originally CMS only allowed this deactivation by the state Medicaid agency through the first quarter of 2013, but since has revised that. CMS will allow state Medicaid agencies to deactivate the edit through the end of 2013. CMS sent out a survey to all State Medicaid agencies. The results show that as of May, 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.

No, the NCCI Edit requirement will not trump any current modifier guidelines required by your state Medicaid agency for EPSDT services. You will simply have to append both modifiers to the preventive medicine services code. While the order should not matter due to the fact that there is no official guidance on the order of reporting modifiers, AAP recommends reporting it as follows in situations where  you are providing an immunization administration in conjunction with a preventive medicine service (eg, code 99392): 
 
99392  25  EP

CPT instructs that when reporting a preventive medicine service in addition to an office or other outpatient E/M code when an acute or chronic illness has to be addressed and is significant and separately identifiable, append modifier 25 to the office or other outpatient E/M code. Now with the new NCCI Edit on the preventive medicine service codes and the immunization administration codes, modifier 25 must be appended to the PMS code to override the edit when the services are reported together. 
 
Example: You see a 9-month old for a well check and the mom also states that the child is favoring her left arm when crawling. You perform a significant and separately identifiable E/M service to address this issue and end up sending the patient for x-rays. You also notice that the patient needs her influenza vaccine and that is administered. Your claim will look as follows: 
 
99391  25 
99212  25 
90655 
90460 
 
 
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