State Medicaid programs have questions about Oct. 1 NCCI edit implementation

The Patient Protection and Affordable Care Act (PPACA) mandates that state Medicaid programs "effective for claims filed on or after Oct. 1, 2010, incorporate compatible methodologies of the National Correct Coding Initiative [NCCI] administered by the Secretary [or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment] and such other methodologies of that Initiative [or such other national correct coding methodologies] as the Secretary identifies. ..."

But states still have some questions about exactly how to implement the NCCI edits, and the National Association of State Medicaid Directors (NASMD) has sent a letter to the Centers for Medicaid and Medicaid Services (CMS) asking for guidance.

"The Correct Coding Initiative edits, which are part and parcel to the CCI methodologies, are released quarterly," noted the NASMD. "It will be important to understand if the intent of CMS is to edit claims against CCI in a 'date sensitive' fashion, only applying the CCI edits for a particular quarter against a claims with a corresponding date that falls within that same quarter. If this is the intent, then Medicaid programs will have to prepare to edit claims 'filed on or after October 1st against NCCI files from previous quarterly releases. If this is not the intent, then CMS must identify the specific NCCI file they wish to use for editing purposes." In addition, the NASMD wants to know whether previously submitted claims that have been mass-adjusted or resubmitted also need to be processed against the NCCI edits.

The NCCI edits are designed to prevent improper payment when providers report incorrect code combinations. Under Medicare, NCCI edits are used to process physician services under the Medicare Physician Fee schedule, as well as outpatient Part B hospital claims and claims from Part B therapy providers.

To learn more:
- read this NASMD letter
- read the consolidated PPACA language on the National Conference of State Legislatures website
- visit CMS' NCCI Edits web page

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