The federal Patient Protection and Affordable Care Act, passed into law in 2010 mandates that effective for claims filed on or after October 1, 2010, State Medicaid Agencies must incorporate and apply editing methodologies of the National Correct Coding Initiative (NCCI). CMS expanded the NCCI editing process and mandated new NCCI edits for additional provider types that will impact claims filed on or after August 1, 2012.

The Centers for Medicare and Medicaid Services (CMS) has been charged by Congress with the responsibility for defining the adjudication rules, and provider types and claim types subject to the NCCI edits. On September 1, 2010, CMS issued these directions to State Medicaid agencies. Additional edits are updated quarterly.

Alaska Medicaid, like all other State Medicaid agencies, is required to enforce these edits within the claims processing environment. Two types of edits are mandated in the law: procedure-to-procedure and unit of service. The potential exists that these edits could impact your claims filed on or after October 1, 2010.

NCCI News and Updates

Effective for claims with dates of service on or after January 1, 2013, new National Correct Coding Initiative (NCCI) edits will be implemented. 

A significant change to procedure to procedure (PTP) edits affects claims for immunization administration and evaluation and management (E&M) codes performed on the same date of service.  The immunization administration codes affected by the new PTP edits are CPT codes in the range of 90460 – 90474.  All E&M services CPT codes, including preventive medicine services (i.e. “well child” and EPSDT visits), are impacted by the PTP edit. 

Immunization administration codes and E&M services can be reported together when an appropriate modifier is appended to either code of the edit pair.  Documentation in the medical record should support the use of an appropriate modifier.