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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.4 Claims Filing Instructions : 6.4.1 National Correct Coding Initiative (NCCI) Guidelines

6.4.1
The Patient Protection and Affordable Care Act (PPACA) mandates that all claims that are submitted to TMHP be filed in accordance with the NCCI guidelines. These guidelines can be found in the NCCI Policy and Medicare Claims Processing Manuals on the CMS website at www.cms.gov/NationalCorrectCodInitEd/.
The NCCI guidelines consist of HCPCS or CPT procedure code pairs that must not be reported together and medically unlikely edits (MUEs) that determine whether procedure codes are submitted in quantities that are unlikely to be correct.
The NCCI and MUE spreadsheets are published and updated by CMS and are available on the CMS Medicaid NCCI Coding web page under “NCCI and MUE Edits” as follows:
NCCI edit spreadsheets. The website contains the Medicaid NCCI edit spreadsheet for hospital services and the Medicaid NCCI edit spreadsheet for practitioner services. The spreadsheets list the procedure code pairs that will not be reimbursed separately if they are billed by the same provider with the same date of service. Column 1 procedure codes may be reimbursed and Column 2 procedure codes will be denied. The spreadsheets also contain a column that indicates whether or not a modifier is allowed for services that may be reimbursed separately.
MUE edit spreadsheets. The website contains the Medicaid MUE edit spreadsheets for hospital services, practitioner services, and supplier services. The spreadsheets list procedure codes and the number of units that may be reimbursed for each procedure code. Units that are submitted beyond these limitations will be denied.
HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual and the Texas Medicaid Bulletin are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals or bulletins. Providers should refer to the CMS NCCI web page at www.cms.gov/MedicaidNCCICoding/ for correct coding guidelines and specific applicable code combinations.
When Texas Medicaid medical policy is more restrictive than NCCI MUE guidance, Texas Medicaid medical policy prevails.

Texas Medicaid & Healthcare Partnership
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