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December 2016 Texas Medicaid Provider Procedures Manual

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, including claims for services that have been prior authorized or authorized with medical necessity documentation.
The CMS NCCI and MUE guidelines can be found in the NCCI Policy and Medicare Claims Processing manuals, which are available on the CMS website.
The NCCI guidelines consist of HCPCS or CPT procedure code pairs that must not be reported together and 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.
Note:
Providers are required to comply with NCCI and MUE guidelines as well as the guidelines that are published in the Texas Medicaid Provider Procedures Manual, all currently published website articles, fee schedules, and all other application information published on the TMHP website at www.tmhp.com. In instances when Texas Medicaid medical policy is more restrictive than NCCI or MUE guidance, Texas Medicaid medical policy prevails.
HHSC continue to implement and enforce correct coding initiatives. Providers may see additional claim denials related to NCCI and MUE edits including those services that were prior authorized or authorized with medical necessity documentation.
If a rendered service does not comply with a guideline as defined by NCCI, medical necessity documentation may be submitted with the claim for the service to be considered for reimbursement; however, medical necessity documentation does not guarantee payment for the service.
Important:
Prior authorization and authorization based on documentation of medical necessity is a condition for reimbursement; it is not a guarantee of payment.
Claims that were submitted with dates of service from October 1, 2010, through June 30, 2013, will not be reprocessed in accordance with the NCCI guidelines; however, any claims with dates of service on or after October 1, 2010, that are appealed or reprocessed for reasons other than NCCI auditing will be subject to NCCI auditing guidelines.

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