Va. DMAS Hospice Provider Manual ch. V, ClaimsXTen/Correct Coding Initiative (CCI)

DMAS utilizes the Medicaid-specific National Correct Coding Initiative (NCCI) edits

through ClaimsXTen/CCI. NCCI is part of the daily claims adjudication cycle on

concurrent basis. The current claim will be processed to edit current and historic claims.

Any adjustments or denial of payments from the current or historic claim(s) will be done

during the daily adjudication cycle and reported on the providers weekly remittance cycle.

All ClaimsXTen/CCI edits are based on the following global claim factors: same member,

same provider, and same date of service or date of service is within established pre- or

post-operative period.

Procedure-To-Procedure (PTP) Edits:

CMS has combined the Medicare Incidental and Mutually Exclusive edits into a new PTP

category. The PTP edits define pairs of CPT/HCPCS codes that should not be reported

together. The PTP codes utilize a column one listing of codes to a column two listing of

codes. In the event a column one code is billed with a column two code, the column one

code will pay, the column two code will deny. The only exception to the PTP is the

application of an accepted Medicaid NCCI modifier. Note: Prior to this implementation,

DMAS modified the CCI Mutually Exclusive edit to pay the procedure with the higher billed

charge. This is no longer occurring, since CMS has indicated that the code in column one

is to be paid regardless of charge.

Medically-Unlikely Edits (MUE):

DMAS implemented the Medicaid NCCI MUE edits. These edits define for each

CPT/HCPCS code the maximum units of service that a provider would report under most

circumstances for a single member on a single date of service and by same servicing

provider. The MUEs apply to the number of units allowed for a specific procedure code,

per day. If the claim units billed exceed the per day allowed, the claim will deny. With the

implementation of the MUE edits, providers must bill any bilateral procedure correctly.

The claim should be billed with one unit and the 50 modifier. The use of two units will

subject the claim to the MUE, resulting in a denial of the claim.

Modifiers:

DMAS only allows the Medicaid NCCI associated modifiers as identified by CMS for the

Medicaid NCCI. The modifier indicator currently applies to the PTP edits. The application

of this modifier is determined by the modifier indicator of “1”or “0” in the listing of the NCCI

PTP column code. The MUE edits do not contain a modifier indicator table on the edit

table. Per CMS, modifiers may only be applied if the clinical circumstances justify the use

of the modifier. A provider cannot use the modifier just to bypass the edit. The recipient’s

medical record must contain documentation to support the use of the modifier by clearly

identifying the significant, identifiable service that allowed the use of the modifier. DMAS

or its agent will monitor and audit the use of these modifiers to assure compliance. These

audits may result in recovery of overpayment(s) if the medical record does not

appropriately demonstrate the use of the modifiers.

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI

PTP edit include: E1 –E4, FA, F1 – F9, TA T1 – T9, LT, RT, LC, LD, RC, LM, RI, 24, 25,

57, 58, 78, 79, 27, 59, 91. Modifiers 22, 76 and 77 are not Medicaid PTP NCCI approved

modifiers. If these modifiers are used, they will not bypass the Medicaid PTP NCCI edits.