Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
www.mass.gov/masshealth
	
	MassHealth
	All Provider Bulletin 209
	April 2011




	TO:	All Providers Participating in MassHealth

	FROM:	Terence G. Dougherty, Medicaid Director

	RE:	Medicaid National Correct Coding Initiative


Background

Section 6507 of the federal Affordable Care Act (Public Laws 111-148 
and 111-152), as implemented by the Centers for Medicare & Medicaid 
Services (CMS), requires state Medicaid agencies to incorporate 
compatible methodologies of the National Correct Coding Initiative 
(NCCI). NCCI was implemented by CMS to promote national correct 
coding methodologies and to control improper coding to minimize 
inappropriate payment. This requirement is effective for MassHealth 
claims with dates of service on or after October 1, 2010, that are 
processed on or after April 1, 2011.  


Procedure-to Procedure Code Pair Editing	

MassHealth implemented Medicare NCCI procedure-to-procedure code pair
editing during its conversion to NewMMIS. Medicaid NCCI adds 
some additional code pairs for NCCI editing. NCCI code pair edits are 
automated prepayment edits that prevent improper payment when certain 
codes are billed by the same provider for the same member on the same 
date of service.

Full lists of Medicaid NCCI edit code pairs can be found on the CMS Web 
site at 
 
http://www.cms.gov/MedicaidNCCICoding/06_NCCIandMUEEdits.asp#To
pOfPage. 

The above link is included in this bulletin for the sole purpose of providing 
access to the NCCI edit code pairs lists (e.g., see below for MassHealth 
modifier policy). CMS may update these lists. Providers should 
periodically review these lists for changes that CMS may make to them. 
MassHealth may need to periodically reprocess claims to edit against 
updated lists. Note that MassHealth applies NCCI procedure-to-
procedure editing to all providers who bill using HCPCS/CPT codes.

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Medically Unlikely Edits (MUE) Limits

Medicaid NCCI includes Medically Unlikely Edits (MUEs). MUEs are units-of-
service edits that define for certain HCPCS/CPT codes the number of units of 
service beyond which the reported number of units of service is unlikely to be 
correct (for example, claims for excision of more than one gallbladder or more 
than one pancreas). Full lists of Medicaid NCCI MUEs can be found on the CMS Web 
site at 

http://www.cms.gov/MedicaidNCCICoding/06_NCCIandMUEEdits.asp#To
pOfPage. 
 
The above link is included in this bulletin for the sole purpose of providing 
access to the NCCI MUE lists. CMS may update these lists. Providers 
should periodically review these lists for changes that CMS may make to 
them. MassHealth may need to periodically reprocess claims to edit 
against updated lists. Note that MassHealth applies the MUE limits to all 
providers who bill using HCPCS/CPT codes.   


Claims Processing

Claims for dates of service on or after October 1, 2010, that are 
processed on or after April 1, 2011, and are billed using HCPCS/CPT 
codes will be edited for NCCI procedure-to-procedure edits. Any claims 
using HCPCS/CPT codes that include code pairs on the NCCI edit list will 
result in payment denials unless the applicable MassHealth payment 
method does not use these HCPCS/CPT codes to determine the current 
payment amount. 

Claims for dates of service on or after October 1, 2010, that are 
processed on or after April 1, 2011, and are billed using HCPCS/CPT 
codes will be edited against the MUE limits. Any claims using 
HCPCS/CPT codes billed with units of service greater than the MUE limit 
will result in payment denials unless the applicable MassHealth payment 
method does not use these HCPCS/CPT codes to determine the current 
payment amount. 

MassHealth will apply these methodologies to all claims containing the 
applicable HCPCS and CPT codes.  

Due to the timing of system updates, MassHealth may need to later 
reprocess and adjust claims processed during April 2011, to ensure 
proper NCCI editing.

(continued on next page)





Claims Processing (cont.)

Note that MUE limits and procedure-to-procedure code edits 
supersede any approved prior authorizations (PA) in the system. 
Claims over the MUE limit or that include code pairs on the NCCI 
edit lists will be denied even if they have an approved PA that 
would otherwise allow coverage of the service. If a claim with such 
an approved PA is denied solely due to the NCCI denial reasons 
specified below, providers should request an agency review of the 
denial using the process described below. 

       
Agency Review and Appeals

A provider whose claim for payment is denied due solely to a procedure-
to-procedure code edit or an MUE edit may request MassHealth review of 
the denial.  Claims denied for these reasons will have the following denial 
reasons/codes. 

5927 – NCCI - Another Service Prev Paid – Same Claim
5928 – NCCI - Another Service Prev Paid – Other Claim
5929 – NCCI - Conflict With Other Service Prev Paid
5930 – MUE Units Exceeded

Requests for MassHealth agency review of claims denials that include 
additional denial reasons or are denied for any other reasons must follow 
the current resubmittal processes specified in 130 CMR 450.323. The 
review process described herein is only for denials due solely to a 
procedure-to-procedure code edit or an MUE edit with a denial reason 
listed above.  

Pursuant to such a request, the provider must demonstrate that 
(1)	the service for which payment was denied was a medically necessary 
MassHealth-covered service for the member; 
(2)	the provider’s claim was properly completed and submitted in 
accordance with all MassHealth requirements; 
(3)	the provider satisfied all other prerequisites for payment; 
(4)	payment was denied solely due to a procedure-to-procedure or MUE 
edit; and 
(5)	the service is otherwise payable under MassHealth’s coverage, billing, 
and payment rules. 

A provider must file its request for MassHealth agency review, 
accompanied by all supporting documentation, within 30 days of the date 
on the remittance advice on which the claim denial appears, to the 
following address.

MassHealth
ATTN: Prior Authorizations/NCCI 
100 Hancock Street, 6th floor
Quincy, MA  02171
  
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Agency Review and Appeals (cont.)

The provider’s request for MassHealth agency review must include the 
following information:
?	a legible paper copy of the denied claim;
?	a copy of the section of the remittance advice that includes as the sole 
reason for denial one or more of the denial reasons listed on page 3 
of this bulletin;
?	medical documentation sufficient to support a determination by 
MassHealth that the service for which payment was denied is 
medically necessary in accordance with 130 CMR 450.204, or the 
prior authorization number assigned by MassHealth for the service, if 
applicable;
?	the provider name, provider identification number/service location 
(PID/SL), and contact information; and
?	any other information that MassHealth requires after submission of 
the initial request.

MassHealth or its designee will review the documentation submitted by 
the provider and either pay or deny the claim. If the claim is denied, the 
denial notice will include the right to file a claim for an adjudicatory 
hearing and instructions to file such a claim. 

A provider must request MassHealth review and meet all requirements 
specified herein in order to preserve its right to file a claim for an 
adjudicatory hearing and its right to judicial review. 


Modifier Not Covered Denials

CMS’s current list of NCCI-related modifiers is: 25, 27, 58, 59, 78, 79, 91, 
LT, RT, E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, 
RC, TA, T1, T2, T3, T4, T5, T6, T7, T8, and T9.

Use of Modifiers  

Modifiers associated with NCCI may not be covered by MassHealth for 
certain codes and certain provider types. Providers must consult 
Subchapter 6 of their applicable MassHealth provider manual or other 
MassHealth guidance such as transmittal letters and payment and 
coverage guidelines tools specific to their programs, to determine if any 
modifiers are covered and, if so, with which codes they can be used.  
	
If the provider submits a claim with a modifier that is not covered, the 
claim will be denied with reason “Modifier not covered.” Providers may not 
request agency review using the process described above if payment was 
denied for this reason. To receive one of the four denial reasons listed on 
page 3 of this bulletin and the associated right to request agency review 
as described above, providers must bill the claim without the modifier. 

(continued on next page)



Duplicate claim denials

Billing units on separate claim lines to remain under an MUE limit may 
result in the following denial reasons.

5010 – Exact Duplicate - Outpatient Claim
5032 – Exact Duplicate - Outpatient Procedures 
5044 – Exact Duplicate - Physician Claim

Providers may not request agency review using the process described 
above if payment was denied for these reasons. To receive the “MUE 
units exceeded” denial reason and the associated right to request agency 
review as described above, providers must bill the total units on one claim 
line.


Questions

If you have any questions about the information in this bulletin, please 
contact MassHealth Customer Service at 1-800-841-2900, e-mail your 
inquiry to providersupport@mahealth.net, or fax your inquiry to 
617-988-8974.
  


			MassHealth
			All Provider Bulletin 209
			April 2011
			Page 5