Medicaid NCCI Compliance

Re: Mandatory State Use of National Correct Coding Initiative

The Patient Protection and Affordable Care Act requires Medicaid programs to adopt compatible methodologies of the Medicare National Correct Coding Initiative (NCCI) effective for claims filed on and after October 1, 2010.Included with the mandate for NCCI is a requirement for States to implement The Centers for Medicare and Medicaid Services (CMS) Medically Unlikely Edits (MUE) within the same timeframe. Bloodhound’s ConVergence Point editing solution offers fully-sourced CMS NCCI and MUE modules for both professional and outpatient facility claims.

The NCCI/MUE mandate is part of a larger trend towards the adoption of open-sourced national coding standards and a movement away from proprietary coding edits developed by third party vendors, which have led to lawsuits from providers2. The primary standards bodies for coding are the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA). Medicaid payers should note that Bloodhound Technologies uses only fully sourced edits in our rules engine; not just for our NCCI and MUE modules but for all of our edit modules. This allows our clients to implement ConVergence Point with confidence.

Bloodhound has incorporated NCCI edits and other CMS edits into our rules engine for the last 9 years. That said Bloodhound elected to wait until CMS released formal instructions rather than assume compliance and potentially misinform Medicaid payers. With CMS’ release of SMD #10-017 on September 1, 2010, we can confidently state that our solution can apply NCCI and MUE rules in compliance with the requirements set forth by CMS. CMS has provided states with the MCDNCCI file representing the NCCI and MUE edits applicable to Medicaid payers. Bloodhound is implementing these edits on behalf of its Medicaid payers and in compliance with CMS guidelines. Our reporting services easily accommodate CMS’ requirement that, “States will be required to report the savings accrued as a result of the NCCI initiative in Medicaid.”

CMS developed the NCCI to promote national correct coding methodologies and to control improper coding. The coding policies are based on coding conventions defined in the AMA's Current Procedural Terminology (CPT) Manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, and/or current coding practice. The edits include table-based and narrative-based edits.

CMS developed MUE to address services where the frequency of occurrence is identified as “medically unlikely.” An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. In short, these edits are CMS-sourced frequency thresholds.

Bloodhound’s application of CMS NCCI/MUE edits and other rules highlight a number of the differentiators of our solution offering:

Full Service Maintenance-Free Compliance:

Bloodhound designed our solution to easily and effectively update and maintain our edit library as a service inclusive of our offering. NCCI edits fire based on the date of service in relation to the effective dates of the edit as determined by CMS. Our technology enables us to maintain our clinical rule sets with extreme efficiency, so that NCCI edits, which are updated quarterly are fully implemented in our rules engine on their effective date. This includes any client customizations to NCCI edits. This all occurs without the need client involvement or resources.

Also, if a State payer administers different lines of business—SCHIP, corrections, State Teachers, etc.—our rules engine can accommodate any variations in payment policies across those business lines.

Robust Modifier Logic:

Bloodhound’s rules engine can process all modifiers submitted on a claim. This is extremely important to accurately identify CCI edits while eliminating false firings that incur provider unrest. CMS has approved several modifiers that can be used specifically with CCI code pairs. These modifiers are E1-E4, FA, F1-F9, LC, LD, LT, RC, RT, TA, T1-T9, 25, 58, 59, 78, 79 and 91. When one of these modifiers is submitted on a claim involving a CCI code pair, ConVergence Point overrides the CCI edit because the modifier indicates that the procedures were performed at a different site, in a different session, or as a distinct service. The only exception is when the GB Indicator designates a modifier may never be used.

History Based Editing:

Bloodhound applies our edits against total patient history with the payer, which is crucial for compliance as NCCI operates on code pair combinations and an editing system must be capable of referring to patient history to determine if any of the code pairs have previously been submitted on relevant provider claims. Without full history editing a payer will likely overpay claims where code pairs crossover claims.

Provider Transparency:

As the Section 6507 mandate is implemented, Bloodhound believes that Medicaid payers should expect an increase in customer support calls. Our web-tools and portal, which are offered inclusive of our service, can help with increased customer service calls by providing a common platform with full source documentation for internal staff to read from. We can also embed edit results, with source documentation from CMS, into a Medicaid payer’s existing provider portal. Medicaid clients who use the provider portal report a significant decrease in provider inquiries.

Integration: Easy, Flexible and Non-Disruptive

With the mandate fast approaching, Bloodhound offers Medicaid payer’s workflow flexibility for ease of implementation and minimization of I.T. resources and disruption. Bloodhound’s internal technical team developed our solution and are experts at deploying it with no external consultants required. Bloodhound can mimic current editing integrations, if applicable, thereby utilizing a Medicaid payer’s current workflows, editing interface, and data extract as much as possible which minimizes implementation effort or develop new, potentially more beneficial, workflows as well.

Clinical and Policy Consulting:

As part of Bloodhound’s service offering, our clinical staff customizes our solution to exactly match the reimbursement policies of our clients. Under the supervision of our Chief Medical Officer, our internal Clinical Content group constantly reviews and updates our core databases of clinical edits and implement payer specific customizations as requested. They also work with payers to help align payer rules and policies with national standards. For example, in cases where a Medicaid payer might have homegrown edits in place, we can work with them to identify NCCI (or other sourced rules) that are applicable.

Consistent, Inclusive Pricing

Variable costs are anathema to State payers and Bloodhound offers our solution inclusive of all our services. Our transparent pricing includes all edit modules from CMS and the AMA, all customizations, ongoing updates and maintenance, new releases, reports, web portal and clinical consulting.

While other vendors sell supplemental systems and services to address the deficiencies in their existing products, our solution is all-inclusive and requires no additional purchases or supplemental functionality from Medicaid payers.

Bloodhound is the leading advocate of the use of national standards in coding. We stand ready to support Medicaid payers with an inclusive product and service offering that blends cutting edge technology with deep clinical and Medicaid domain expertise.

Sincerely,

Gary Twigg, President
Richard Wheeler, MD, Chief Medical Officer