Claims Billing Information


Medicaid National Correct Coding Initiative (NCCI) Program

Medicaid National Correct Coding Initiative (NCCI) Program: implements NCCI methodologies in State Medicaid programs to reduce improper coding and inappropriate payment of Medicaid claims.

The National Correct Coding Initiative (NCCI) contains two types of edits:

  1. NCCI procedure-to-procedure (PTP) edits that define pairs of Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons. The purpose of the PTP edits is to prevent improper payments when incorrect code combinations are reported.
  2. Medically Unlikely Edits (MUEs) define for each HCPCS / CPT code the maximum units of service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service.

The Medicaid NCCI program consists of six methodologies. These are:

  1. A methodology with PTP edits for practitioner and ambulatory surgical center (ASC) services.
  2. A methodology with PTP edits for outpatient hospital services (including emergency department, observation, and hospital laboratory services).
  3. A methodology with PTP edits for durable medical equipment (as of October 2012).
  4. A methodology with MUEs for practitioner and ASC services.
  5. A methodology with MUEs for outpatient hospital services for hospitals.
  6. A methodology with MUEs for durable medical equipment.

The Medicaid NCCI methodologies apply only to Medicaid fee-for-service claims that are reimbursed on the basis of HCPCS / CPT codes.

Components of the NCCI Methodologies in Medicaid

Each of the Medicaid NCCI methodologies has four components. These are:

  1. a set of edits;
  2. definitions of types of claims subject to the edits;
  3. a set of claim adjudication rules for applying the edits; and
  4. a set of rules for addressing provider appeals of denied payments for services based on the edits.

Information on claim adjudication rules for applying the Medicaid NCCI methodologies in state processing of Medicaid claims, the third component of the Medicaid NCCI methodologies, is contained in the Medicaid NCCI Edit Design Manual

Medicaid NCCI Edit Files

The complete updated Medicaid NCCI off-site link edit files are posted on The Centers for Medicare and Medicaid Services (CMS) at the beginning of each calendar quarter. These files completely replace the Medicaid NCCI edit files from previous calendar quarters. The presence of a HCPCS / CPT code in a PTP edit or of an MUE value for a HCPCS / CPT code does not necessarily indicate that the code is covered by any state Medicaid program or by all state Medicaid programs.

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Ingenix Claims Edit System (iCES)

Ingenix Claims Edit System (iCES) automatically reviews and edits claims submitted by physicians and facilities. The system automatically detects coding errors related to unbundling, modifier appropriateness, diagnoses, and duplicate claims. The iCES system will improve the accuracy of claims payment for all provider types (i.e. physicians, facilities, and suppliers), in accordance with the required editing protocols for the TennCare program.

ICES Billing Tips

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CMS UB 04

The UB-04 is a uniform institutional provider bill and is acceptable for use in billing multiple third party payers. The National Uniform Billing Committee (NUBC) maintains lists of approved coding to use in this form.

The National Uniform Billing Committee (NUBC) is responsible for the design and printing of the UB-04 form. The NUBC is a voluntary, multidisciplinary committee that develops data elements for claims and claim-related transactions, and is composed of all major national provider and payer organizations (including Medicare and Medicaid).

Additional information is available to subscribers of the Official UB-04 Data Specifications Manual. Visit the NUBC website at http://www.nubc.org off-site link to subscribe.

Visit: http://www.bcbst.com/providers/forms/
Claims filing tips are also available in the provider manual.

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CMS 1500

The Form CMS-1500 (Health Insurance Claim Form) is sometimes referred to as the AMA (American Medical Association) form. The Form CMS-1500 is the prescribed form for claims prepared and submitted by physicians or suppliers.

Visit: http://www.bcbst.com/providers/forms/
Claims filing tips are also available in the provider manual.

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Remittance Explanation Codes

The Commercial Remittance Advice Code Descriptions reflect those found on hardcopy (paper) Commercial remittance advice. These same codes and descriptions will also apply to online Commercial remittance advices, available on BlueAccess, the secure area of www.bcbst.com off-site link.

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Billing Telemedicine Originating Site Fees

BlueCare Tennessee reimburses for services rendered via Telemedicine in accordance with BlueCare Tennessee, the Centers for Medicare & Medicaid Services (CMS), and TennCare Guidelines. Qualifying codes under BlueCare Tennessee are consistent with CMS, and TennCare guidance. By filing claims for encounters rendered via Telemedicine, providers are attesting that said claims were rendered according to these rules and guidelines.

Effective September 1, 2013, Originating Sites may bill and receive payment for Q3014 when the Originating Site is not affiliated with the Distant Site practitioner. For the Originating Site, code Q3014 is allowed for each qualifying unit of service received via Telemedicine.

For Distant Site practitioners, the qualifying encounter code should include a GT modifier to indicate the service was delivered via Telemedicine. While it is acceptable to render services via Telemedicine from satellite to satellite as a convenience for multi-site providers (as indicated by a GT modifier), it is not appropriate to bill Q3014 under these circumstances.

Q3014 billing will be audited and dollars recouped where billed outside policy and/or if billed when no corresponding GT encounter is on file for the date of service. Medicare guidance can be found at the website links listed below.

Resources

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Emergency Services Reimbursement

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