Claim Payments: National Correct Coding Initiative Effective March 28

Effective March 28, 2011, claims processed with dates of service retroactive to October 1, 2010, will have National Correct Coding Initiative (NCCI) edits applied. Providers are encouraged to visit the CMS NCCI Edits Overview page to learn more about this nationally mandated program that will affect the way Medi-Cal processes claims. Implementation of NCCI may result in reduced provider payments because NCCI edits are designed to prevent inappropriate reimbursement of services including, but not limited to services that are: • Mutually exclusive • Inappropriately bundled (a comprehensive service billed with a component service) • Billed with too many units of service (medically unlikely) Claims Already Submitted Claims with dates of service on or after October 1, 2010, which were processed prior to the implementation of NCCI on March 28, 2011, will not be reprocessed to enforce NCCI edits; however, claims processed or reprocessed on or after March 28, 2011, with dates of service on or after October 1, 2010, will be subject to NCCI claim edits. In the Medi-Cal processing system, claims will process for NCCI edits before being processed for Medi-Cal edits. NCCI procedure to procedure edits and MUE limits are applied to services performed by the same provider for the same recipient on the same date of service. A TAR or medical justification submitted with the claim may be allowed to override an NCCI Medically Unlikely Edit. That is, where medical justification is currently allowed to override a Medi-Cal edit, this justification may be considered for a quantity greater than that allowed by the MUE. Source: General Medicine | February 2011 | Bulletin 440


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