J.1 NCCI.SOW. 2019-2024 .docx

Section C – Statement of Work National Correct Coding Initiative

September 26, 2018

I. SCOPE

The contractor shall be responsible for supporting the National Medicare and Medicaid Correct Coding Initiative (NCCI), a Center for Medicare and Medicaid Services (CMS) initiative to prevent improper payments and promote consistent coding for national programs. The NCCI program functions to promote program integrity and compliance through guidance, edits, and other methodologies that promote the consistent administration of CMS payment policies in instances where the manipulation of coding could lead to inappropriate, increased reimbursements. At a minimum, the contractor shall be responsible for:

- maintaining Procedure to Procedure (PTP), Add-On Code (AOC) and related edits, including updating the current edits with any recommended changes or comments and incorporating Current Procedural Terminology (CPT) additions, deletions, and revisions;

- maintaining the Medically Unlikely Edits (MUEs) (Units-of-Service Edits) to reduce coding and clerical errors;

- assisting CPI as it assists the Center for Medicare (CM) in evaluating clinical and claim information to ensure that NCCI accurately reflects CM payment and policy decisions; and

- assisting CPI as it assists the Center for Medicaid and CHIP Services (CMCS) and the states in meeting the requirements of section 6507 of the Patient Protection and Affordable Care Act (PPACA).

A. Background

As the largest payer for healthcare services, CMS covered programs are a target for improper payments and schemes to defraud federal healthcare programs of billions of dollars annually. The Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239), Section 6102, amended Title XVIII of the Social Security Act (the Act) by adding a new section 1848, “Payment for Physicians' Services.” This section of the Act provided for replacing the previous reasonable charge mechanism of actual, customary, and prevailing charges with a resource-based relative value scale (RBRVS) fee schedule that began in 1992. The implementation of the Medicare Fee Schedule under the Physician Payment Reform required the CMS, formally known as the Health Care Financing Administration, to adopt uniform payment policies and procedures for all physicians.

In February 1991, CMS instructed all carriers to enact a system of edits limiting the overpayment for codes that had been unbundled. The methodology referred to as "re-bundling", consisted of a CMS defined list of 87 codes which were defined in the Medicare Carriers Manual as being either a Comprehensive (Column 1) or Component (Column II) code. Component codes are denied if submitted by the same provider, for the same beneficiary, for the same date of service. In 1992, the list of codes was expanded to 252 codes. With the implementation of the Medicare Physician Fee Schedule, it was important to assure that uniform payment policies and procedures were followed by all carriers (A/B Medicare Administrative Contractors (MACs) processing practitioner service claims), so that the same service would be paid similarly in all carrier (A/B MAC processing practitioner service claims) jurisdictions. Accurate coding and reporting of services by physicians is a critical aspect of assuring proper payments. To address this requirement, CMS developed and implemented the NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. In August 1994, CMS awarded the first NCCI contract to further develop a list of re-bundling edits for Medicare Part B carriers.

On January 1, 1996, Medicare carriers went "live" with Correct Coding Initiative (CCI) edits. The edits consisted of two methodologies, (1) the comprehensive/component table, and (2) the mutually exclusive table. Claims are denied by CCI edits based on a determination of inappropriate coding, not on the basis of medical necessity. Correct Coding is a separate activity from medical review in that no further clinical judgment is needed to deny a claim. Therefore, the denial can be automated. On April 1, 1997, the CCI file formats were expanded to include a Correct Coding Modifier (CCM) indicator. This indicator specifies which edits may or may not be bypassed with a modifier. The following are the modifier indicators: CCM 0 identifies PTP edits for which no modifier is allowed; CCM 1 identifies edits for which a modifier could be appropriate; and CCM 9 identifies PTP edits, which have been deleted retroactively to their implementation date.

Currently, the Medicare PTP program includes over 2.8 million active procedure-to-procedure edits distributed across multiple processing systems. As a result of the escalating costs of health care, the growing complexity of coding, the growing volume of claims, and the parallel decrease in funding for carrier activities, CMS must continue to control inappropriate payments. Incorporating additional correct coding methodologies into the claims processing systems will continue to provide significant savings to the Medicare program and promote payment equity/consistency through the reduction of inappropriate overpayments.

Medically Unlikely Edits (MUEs) were implemented on January 1, 2007, and were created in order to ensure that Medicare pays for services appropriately. Congress mandated replacement of cost based hospital outpatient payment with a prospective payment methodology. The Balanced Budget Act of 1999 enacted on November 29, 1999, made changes that affected the hospital outpatient payment. The Outpatient Prospective Payment System (OPPS) was implemented for services furnished after August 1, 2000. Under OPPS, in order to properly pay for claims, the correct number of units of service must be submitted. MUEs reduce payments for incorrect units of service and incorrect (Healthcare Common Procedure Coding System) (HCPCS) selection resulting from keystroke errors as well as other billing errors frequently found on claims submissions. The MUE program prevents payment when units of service are billed in excess of the MUE for a specific HCPCS / CPT code for a single beneficiary, typically on a single date of service. Currently, the Medicare MUE program includes over 28,000 active MUEs across multiple processing systems.

Section 6507 of the PPACA required by September 1, 2010, that CMS: 1) identify those methodologies of the NCCI which are compatible to claims filed under Title XIX to promote correct coding and to control improper coding leading to inappropriate payments; 2) identify those methodologies that should be incorporated into claims filed under Title XIX for which no correct coding methodologies have been established with respect to Title XVIII; and 3) notify States of the methodologies identified and the process by which States are to incorporate such methodologies for claims filed on or after October 1, 2010. In a State Medicaid Director Letter, #10-017, States are required to process Medicaid claims using the NCCI methodologies effective for claims filed on or after October 1, 2010. Both sets of edits will be maintained and utilized to reduce coding and clerical errors, which reduces the paid claims error rate. CMS was required to submit a Report to Congress describing the notice to States and an analysis of the methodologies identified above. That Report was submitted on March 11, 2011. Currently, the Medicaid PTP program includes over 3.0 million active procedure-to-procedure edits distributed across multiple processing systems. The Medicaid MUE program includes over 28,000 active MUEs across multiple processing systems.

To further promote correct coding and savings to the Medicare program, MUEs also prevent a provider from billing where it is anatomically impossible (e.g., three leg amputations on the same date of service) or where other regulatory considerations, such as the official code definition, absolutely limit the number of billable units. MUEs specify the number of times a procedure can be performed on the same date of service by the same provider. Effective April 1, 2013, CMS modified the MUE Program (CR 8023) so that most MUE values became date of service edits rather than claim line edits. In order to implement this change, CMS introduced a new data field to the MUE edit table termed "MUE adjudication indicator" or "MAI". Each HCPCS code is assigned a MAI of one (1) (claim line edits), two (2) (regulatory date of service edits), or three (3) (benchmark date of service edits). Effective, January 1, 2015, additional modifications were made to the MUE Program (CR 8853), which included clarifications, general processing instructions and detailed explanations of the MAI 2, MAI 3, ASC, and Method 2 CAH MUEs. MAI of “1” are adjudicated as a claim line edit. These are “per line” edits. MAI of “2” are absolute date of service edit. These are “per day edits based on policy”. MAI of “3” are also date of service edits. These are “per day edits based on clinical benchmarks”. Instructions in CR 8853 are the most current updates and instructions to the MACs. Therefore, refer to CR 8853 for additional information on the MUE Program. Contractor/Staff shall familiarize themselves with all of the information and modifications in CR 8853 as well as other CRs and published guidance related to the NCCI.

In December 2015, the Medicaid Correct Coding Initiative Program was transferred from the CMCS to CPI. To this end, the programs are now integrated as the Medicare and Medicaid National Correct Coding Initiative. Contractor/Staff shall familiarize themselves with all of the relevant statutory language in PPACA, information in the report to Congress and CMS materials related to both Medicare and Medicaid Correct Coding Initiatives.

More detailed information about the National Medicare and Medicaid Correct Coding Initiative Programs is available at:

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html and https://www.medicaid.gov/medicaid/program-integrity/ncci/index.html.

B. Purpose

The purpose of this contract is to:

- maintain and further expand all of the NCCI correct coding edits and other methodologies to ensure that consistent coding and adjudication of Medicare and Medicaid claims leads to consistent payments to providers in accordance with the payment policies of those programs; and

- enable CMS and the States to meet the Medicaid program requirements contained in section 6507 of the PPACA and State Medicaid Director Letter 10-017.

The contract provides for the maintenance of associated manuals and references, maintenance of data files, and the continuation of the ongoing activities necessary to the successful administration of the NCCI program. Such activities include, for example, education to the provider community, replying to correspondence, inquiries, providing requested information for special requests/reports (e.g. OIG/GAO, etc.), and providing support to CMS in the administration and expansion of all CMS Correct Coding initiatives.

The contractor shall provide the necessary personnel, equipment, materials, support / maintenance, supplies and services (unless Government-supplied data, equipment, or supplies are indicated) to accomplish the objectives.

The expected outcomes for this contract are:

· to provide continuous maintenance of the current NCCI PTP, AOC and MUE edit programs and to further develop, improve and expand those programs in order to prevent improper payments

· to provide continuous maintenance of the CCI Coding Policy Manual and the CCI Correspondence Language manual or their successors, and to develop, improve and expand the content and/or format in order to support the edits and guidelines promulgated by NCCI;

· to provide timely and accurate answers to inquiries received from email, correspondence, fax, resource mailbox, etc. about the NCCI program, while tracking this activity through an internal inquiry log that is directly accessible to CMS to monitor existing edits to identify inaccuracies or changes, making any necessary corrections upon approval from CMS;

· to provide appropriate surveillance of healthcare coding systems in order to recommend necessary additions, deletions and changes to the NCCI edit programs;

· to assist CMS in identifying opportunities to create new programs, approaches and strategies to reduce Medicare and Medicaid coding variation and associated payment variation, ensure correct, consistent coding and associated payments in accordance with Medicare and national Medicaid policies, and to reduce overpayments associated with inappropriate coding;

· to establish and maintain databases directly accessible to CMS to support deliverables related to the requirements of this contract to provide an audit trail pertaining to all decisions relating to the edits and records of the status of all edits at any point in time;

· to establish and provide quarterly data file replacements compatible with CMS requirements for transmission of the data to the claims processing systems;

· to establish and provide an audit trail capable of supporting records to support NCCI Workgroup (WG) decisions and actions for use in responding to queries or other administrative needs; and

· to ensure that the requirements contained in section 6507 of the PPACA are met, namely, that CMS notify States of NCCI methodologies that are “compatible” with claims filed with Medicaid to promote correct coding and control improper coding leading to inappropriate payment of claims under Medicaid, that CMS notify States of the NCCI methodologies (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) that should be incorporated for claims filed with Medicaid for which no national correct coding methodology has been established for Medicare, and that CMS inform States as to how they must incorporate these methodologies for claims filed under Medicaid.

II. REQUIREMENTS

Independently and not as an agent of the Government, the contractor shall furnish all of the necessary services, qualified personnel, materials, equipment, and facilities, not otherwise provided by the Government, as needed to perform the requirements of the Statement of Work (SOW).

The following are System and Manual Requirements:

· Claims Processing Manual, Pub 100-04, Chapter 23, Section 20.9 (Correct Coding Initiative)

· Claims Processing Manual, Pub 100-04, Chapter 12, Section 30 (Correct Coding Policy)

A. General

The contractor shall ensure that all the work performed under the contract is in accordance with requirements identified herein.

In addition to the SOW requirements, CMS is interested in finding and implementing new and innovative approaches for performing NCCI activities. The contractor shall suggest innovative techniques to CMS and implement approved innovations as appropriate for NCCI to be accomplished under this SOW.

CMS reserves the right to expand upon or add to the tasks identified within this SOW, as well as the workload identified herein, as required and in the best interests of the Government. Expansions and adjustments that can be accomplished through the redirection of existing contractor resources (including costs) shall be executed at the direction of the COR; expansions and adjustments that require additional contractor resources (including costs) must be executed through modifications of the contract.

The contractor shall use all appropriate CMS Medicare and Medicaid data, as well as data from other public sources and private sources made available to the contractor or acquired by the contractor under the terms of the contract executed to accomplish this SOW. To promote open access to the policies, processes and tools that ensure accurate billing and payment to Medicare and Medicaid programs, the government shall have rights in data, including items such as edits, rationales, models, concepts, approaches, and software in accordance with FAR clause 52.227-17 Rights in Data - Special Works.

The NCCI Contractor shall accomplish the above objectives by performing the tasks listed below. The intent of this SOW is to capture all the work being performed under the prior CCI contract while providing additional structure and direction.

TASK GROUP 1: CONTRACT MANAGEMENT

Task 1: Initial Kick-off Meeting/Conference

The contractor shall participate in a kickoff meeting with CMS at CMS’ Baltimore, MD, Central Office location within fifteen calendar days after award of the contract. The contractor and the Contracting Officer’s Representative (COR) shall mutually determine the time and date of this meeting/conference.

The contractor shall develop and deliver a presentation at the kick-off meeting that includes the following:

- introduction of key personnel;

- an overview of the technical approach;

- a description of the Transition Plan;

- a description of the Project Management Plan (PMP); and

- other topics as directed by CMS.

Note: There will be a sixty (60) day transition period beginning at the contract start date between the outgoing contractor and the incoming contractor. Refer to Task 23.

Task 2: Draft and Final Project Management Plan

The contractor shall prepare and submit to CMS a detailed Project Management Plan (PMP) when there is a substantial change in the Plan. The final first year PMP is due within sixty (60) days of the contract start date. The contactor shall update the PMP if any significant information in the PMP is changed. Subsequent year PMPs shall be submitted no later than 3 months before the end of the current contract year only if there is a substantial change from the year.

The project plan shall cover each task of the requirements for this contract and shall highlight each step of implementation of this contract. The project plan shall include, at a minimum, the following information:

- each Task and its implementation;

- project organization;

- key milestones signifying successful completion of each Task;

- periodic internal assessment / progress reports planned; and

- description on how the contractor intends to use medical specialty societies, State Medicaid Directors, State Medicaid Medical Directors, and others in an advisory capacity with regard to proposed edits.

The PMP shall be updated as necessary to include any projects (special deliverables) undertaken by the contractor.

Task 3: Onboarding Plan

The onboarding plan includes the steps the contractor needs to make to successfully assume the operational work of this contract. The draft onboarding plan shall be included in Task 2 and submitted at the kick-off meeting. If there are any changes or updates requested by CMS to the onboarding plan during the kick-off meeting, the contractor shall provide the final onboarding plan within three (3) calendar days after the kick-off meeting. . The plan must, at a minimum, specifically detail the steps (with dates) illustrating what and how the contractor shall receive background information, documentation and records and priority tasks for start-up from CMS and the incumbent contractor. The plan shall demonstrate that the contractor will assume responsibility for operations as of the contract start date, and describe how those operations shall be initiated and rapidly brought up to full performance levels. The plan shall include all the necessary information broken out by project phases (i.e., preparation, transfer, and fully operational) and workload. The contractor shall develop an onboarding management team to ensure communication, cooperation, consultation, and coordination between the entities is maintained. The team shall be in place by the kick-off meeting. After the kick-off meeting, the team shall have regular meetings and shall monitor the work of any subgroups during the onboarding phase. The team shall present and provide written weekly status reports to CMS.

TASK GROUP 2: CORE OPERATIONS

Task 4: Procedure-to-Procedure Program

The NCCI PTP program produces edits based on code pairs in which one member of the pair (the column two code) is not payable when the column one code is present on the same date of service. The contractor is responsible for supporting the CMS NCCI-PTP WG to proactively and reactively re-evaluate the existing PTP edits and edit program, to implement changes based on decisions of the WG, to maintain records of the Workgroup activity and WG decisions, to produce output files and public reports, and to assist in the testing of the output files.

Appendix B identifies the most recent existing Medicare and Medicaid PTP edits effective for the practitioner (MCS), hospital (FISS) and DME (VMS) systems as of January 1, 2016. The AMA’s Current Procedural Terminology © (CPT) is updated once annually, with new editions effective January 1st of each year. The contractor shall maintain and update the edits/code pairs identified as a result of the CPT code annual updates. In addition, the contractor shall update the edits / code pairs, as exemplified in the most recent Changes Report identified in Appendix C as a result of the Healthcare Common Procedural Coding System (HCPCS) updates, which are published on a quarterly basis.

The contractor shall identify, develop, propose, and maintain PTP edits using the Physician’s Current Procedural Terminology (CPT), the Healthcare Common Procedural Coding System (HCPCS), and current CMS policies (as demonstrated through manual changes). The contractor shall proactively analyze claims data for the assessment of new proposals and the reassessment of previously released PTP Edits. When detailed analysis is necessary, the contractor receives claims data from CMS or its contractor, extracts the relevant information, summarizes the data for each HCPCS / CPT code pair and contractor type, and creates user-friendly reports for review of PTP issues with CMS in teleconferences. The contractor shall simultaneously consider the PTP program as a whole and review articles, fraud reports, correspondence and/or other information sources in order to identify areas of Medicare and Medicaid overpayments and propose PTP edits, new types of PTP edits or new NCCI programs in order to reduce fraud, waste and abuse and promote consistent payment to providers.

The contractor shall update edits/code pairs on a continual basis using regular WG meetings with CMS. The contractor shall provide administrative support for CMS’ NCCI-PTP Workgroup, developing the Agenda; preparing data, proposals, and reconsideration requests; maintaining a record of WG proceedings; organizing decisions and updating files and correspondence in response; and providing any additional support as required by the WG. WG meetings will occur at least weekly.

The contractor shall, under the direction of CMS, identify relevant National Healthcare Organizations (NHOs) such as from the AMA, specialty societies, CMS components, carrier medical directors, and other individuals or organizations as directed by CMS and circulate proposed edits and edit changes to those entities for comment. The contractor shall incorporate comments into the WG agendas to allow the WG to consider those comments as part of the edit approval process.

The contractor shall re-evaluate existing PTP edits in response to requests for reconsideration by specialty societies, government entities including CMS, or other members of the public. The contractor shall create user-friendly reports/presentations for the WG to identify the issue, present the position proposed by the petitioner, present a contrary position in order to create a balanced presentation, present data to support a decision and present a recommendation to the WG. The decision of the WG shall then be documented by the contractor and implemented as part of the usual PTP process.

The contractor shall develop a single integrated NCCI database for producing, tracking all codes, corrections, and decisions used to produce the PTP edits, and PTP related work products, such as the NCCI manual and meeting agendas. The contractor shall maintain an electronic log of provider inquiries and associated answers regarding Coding Manual changes. CMS and the contractor shall expand the database as necessary to be used for tracking correspondence so that NHO comments, external requests and inquiries can be cross-referenced to specific edits as necessary, and include other information, such as Coding Manual text, in this integrated database in order to reduce contractor and CMS effort. The contractor shall provide CMS with continuous controlled access to the database and the instructions for using it. It would, for example, be acceptable for the Integrated Database to consist of the ACCESS databases made available through SharePoint to CMS on a 24/7 basis. The contractor shall maintain all documents internally and provide electronic documents to CMS as requested.

The contractor shall assist in testing of the Medicare edit changes on a quarterly basis. Testing shall take place no later than 1 month prior to the end of the quarter in order to have the edits go live and be effective in the systems on January 1, April 1, July 1, and October 1 of each year. For each quarterly release, the contractor shall produce an electronic test file and an electronic final file. (See also Task 16 and Deliverable 3.2.) Currently the effective date of the PTP version update for FISS (OCE) is the same as the PTP version update for MCS practitioner services, so all quarterly release files (FISS/OCE, MCS and VMS) have the same due dates to CMS. (The PTP edit file for OCE may be submitted earlier than the MCS and VMS files based on the requirements of the OCE contractor.) The effective date of the practitioner (MCS), OCE (FISS), and DME (VMS) files is thus the first day of the quarter following file submission.

On a quarterly basis, the contractor shall produce a corresponding set of test and final PTP edit files for implementation into the Medicaid program. The effective date of Medicaid edits is the same as the MCS practitioner effective date and the due dates for all Medicaid files is the same as the due date for the corresponding Medicare MCS practitioner file.

CMS will at times require special files for immediate implementation. In those instances, the format will be the same as a format required for quarterly implementation. Such files willbe required within 15 days of the latter of the date of request or the date at which all relevant decisions and data have been delivered to the contractor for inclusion in the PTP database.

To assist in the administration of the PTP process, the contractor shall file an Edit Changes Report on the status of PTP edit initiatives on a quarterly basis. The changes report shall identify all edits that will change in the Medicare and Medicaid programs for the next quarterly version, including additions, deletions and changes, and categorized by practitioner, hospital, and DME subprograms. The contractor shall additionally produce a public reference file of published PTP edit pairs for practitioner, DME supplier and outpatient hospital services. Finally, the contractor shall include PTP activities in its monthly, quarterly and annual Activity Reports to summarize the status of PTP edit initiatives.

Task 5: Medically Unlikely Edits

The NCCI MUE program produces edits in which a service or code (claim line) is denied if the Units of Service (UOS) for the code exceed the MUE value for a specified range, such as a line or date of service. The contractor is responsible for supporting the CMS NCCI-MUE WG to proactively and reactively re-evaluate the existing MUEs and edit programs, to implement changes based on decisions of the WG, to maintain records of the WG activity and WG decisions, to produce output files and public reports, and to assist in the testing of the output files. Appendix B identifies the most recent existing public Medicare and Medicaid MUEs effective for the practitioner (MCS), hospital (FISS) and DME (VMS) systems as of January 1, 2016. Appendix C identifies the Changes Report that documents the public changes in the most recent MUE release.

The contractor shall identify, develop, propose, and maintain MUEs using the Physician’s Current Procedural Terminology (CPT), the Healthcare Common Procedural Coding System (HCPCS), and current CMS policies (as demonstrated through manual changes). The contractor shall proactively analyze claims data for the assessment of new proposals and reassessment of previously released MUEs. The contractor receives claims data from CMS or its contractor, extracts the relevant information, summarizes the data for each HCPCS / CPT code and contractor type, and creates user-friendly reports for review of MUE issues with CMS in teleconferences. The contractor shall simultaneously consider the MUE program as a whole and review articles, fraud reports, correspondence and/or other information sources in order to identify areas of Medicare and Medicaid overpayments and propose MUEs, new types of MUEs or new NCCI programs in order to reduce fraud, waste and abuse and promote consistent payment to providers.

The contractor shall update MUE values on a continual basis using regular WG meetings with CMS. The contractor shall provide administrative support for CMS’ NCCI-MUE WG, developing the agenda; preparing data, proposals, and reconsideration requests; maintaining a record of WG proceedings; organizing decisions and updating files and correspondence in response, and providing any additional support as required by the WG. WG meetings will occur at least weekly and, as necessary to support other NCCI programs if MUE needs are not pressing.

The contractor shall, under the direction of CMS, identify relevant National Healthcare Organizations such as from the AMA, specialty societies, CMS components, carrier medical directors, and other individuals or organizations as directed by CMS and circulate proposed edits and edit changes to those entities for comment. The contractor shall incorporate comments into the workgroup agendas to allow the workgroup to consider those comments as part of the edit approval process.

The contractor shall re-evaluate existing MUEs in response to requests for reconsideration by specialty societies, government entities including CMS, or other members of the public. The contractor shall create user-friendly reports/presentations for the WG to identify the issue, present the position proposed by the petitioner, present a contrary position in order to create a balanced presentation, present data to support a decision and present a recommendation to the WG. The decision of the WG shall then be documented by the contractor and implemented as part of the usual MUE process.

The contractor shall use a single integrated NCCI database for producing, tracking all codes, corrections, and decisions used to produce the MUEs and MUE related work products and documenting agendas. The database shall be used to support the MUE WG in the same fashion that it is used to support the PTP WG.

The contractor shall assist in testing of the Medicare edit changes on a quarterly basis. Testing shall take place no later than 1 month prior to the end of the quarter in order to have the edits go live and be effective in the systems on January 1, April 1, July 1, and October 1 of each year. For each quarterly release, the contractor shall produce an electronic test file and an electronic final file. (See also Task 16 and Deliverable 3.2.) All quarterly release files (FISS/OCE, MCS and VMS) have the same due dates to CMS. The effective date of the practitioner (MCS), OPH (FISS), and DME (VMS) files is thus the first day of the quarter following file submission.

On a quarterly basis, the contractor shall produce a corresponding set of test and final MUE files for implementation into the Medicaid program. The effective date of Medicaid edits is the same as the MCS practitioner effective date and the due dates for all Medicaid files is the same as the due date for the corresponding Medicare MCS practitioner file.

CMS will, at times, require special files for immediate implementation. In those instances, the format will be the same as a format required for quarterly implementation. Such files will be required within 15 days of the latter of the date of request or the date at which all relevant decisions and data have been delivered to the contractor for inclusion in the MUE database.

To assist in the administration of the MUE process, the contractor shall file an Edit Changes Report on the status of MUE initiatives on a quarterly basis. The Changes Report shall identify all edits that will change in the Medicare and Medicaid programs for the next quarterly version, including additions, deletions and changes, and categorized by practitioner, hospital and DME subprograms. The contractor shall additionally produce a public reference file of published MUEs for practitioner, DME supplier and outpatient hospital services for publication on the CMS website. Finally, the contractor shall include MUE activities in its monthly, quarterly and annual Activity Reports to summarize the status of MUE edit initiatives.

Task 6: Medically Unlikely Edits (MUEs) for Drugs and Drug-related HCPCS Codes

HCPCS codes for drugs, drug-related, biologicals and supplies and similar products represent a special subset of the MUE program. The Medically Unlikely Edits (MUEs) shall be developed for HCPCS J codes for drugs and drug-related HCPCS C and Q codes as part of the NCI MUE program for both Medicare and Medicaid. The contractor shall update and expand MUEs for existing J codes and other HCPCS drug codes for use in Medicare and Medicaid subject to limitations imposed by the current processing systems. The contractor shall develop MUEs for new and modified J codes and other HCPCS codes as they become active codes. The contractor shall incorporate this process into the ongoing development of MUEs for other new and modified HCPCS / CPT codes. The contractor shall utilize the MUE review-and-comment process to allow national healthcare organizations (NHOs) to comment about the edits. The contractor shall respond to correspondence about J codes and other HCPCS drug codes in the same manner as it does for MUEs for other HCPCS / CPT codes. That correspondence shall be incorporated into the correspondence log and reconsiderations shall be handled as part of the standard MUE reconsideration process.

The contractor shall work with the CMS NCCI-MUE WG to review, assign and implement the MUEs, integrating them into the current MUE files. The contractor shall meet, as scheduled via teleconference to work with the MUE WG in the review, discussion, assignment, and implementation of drug-related MUEs. Drug and drug-related HCPCS codes will require the contractor to research on-label and off-label indications for these drugs and related codes, and present that information in concert with data describing the usual utilization of the drugs. The contractor shall utilize claims data from the appropriate National Database contractor, shall extract the relevant information, shall summarize the data for each HCPCS / CPT code and contractor type, and shall create user-friendly reports for review of MUE issues with CMS in teleconferences. The contractor will have occasional meetings with the CMS MUE Administrative WG to discuss drug-related MUE administrative issues that arise from the technical meetings, correspondence, email, U.S. mail, telephone, or any other source.

Since MUEs for these codes for suppliers may differ from MUEs for these codes for practitioner claims, the contractor shall develop, if required, a separate MUEs for the practitioner and DME files. These MUEs shall be included in the standard MUE files and represent a subset of that deliverable. The contractor will be required to use the MUE Drug Code approach to prepare edits related to drugs and biologicals for other NCCI subprograms.

Task 7: Add-On Code (AOC) Edits

The NCCI AOC program produces edits based on code pairs in which one member of the pair (the column one or AOC) is not payable unless the column two (primary) code is present on the same date of service. The CMS NCCI-PTP WG oversees the management of this program. The contractor is responsible for supporting the CMS NCCI-PTP WG to proactively and reactively re-evaluate the existing AOC edits and edit program, to implement changes based on decisions of the WG, to maintain records of the WG activity and WG decisions, to produce output files and public reports, and to assist in the testing of the output files. The contractor shall ensure that this task is fully integrated into the support of the PTP workgroup, that the integrated database houses the necessary information to enable that integration and that the solicitation of comments and review of requests for reconsideration are also performed along with the corresponding tasks for PTP edits.

The contractor shall identify all AOCs in the CPT Manual and divide them into three groups. The contractor shall also include an evaluation of any HCPCS Level II codes for AOCs or primary codes. Type I AOCs are codes for which the CPT Manual and/or CMS specifically identifies all the primary codes with which these codes must be reported. For Type I AOCs all primary codes are defined by CMS. Type III add-on codes are those for which the CPT Manual and or CMS have identified some but not all possible primary codes. CMS defines a base set of primary codes but MACs may add additional primary codes based on local coding decisions. The NCCI contractor shall develop an edit file listing in column one the AOC and in column two the primary codes for Type I and Type III add-on code pairs defined by CMS. Type II AOCs are codes for which the CPT Manual and/or CMS do not specifically identify the primary codes but for which CMS has determined that a primary code is required. It is the responsibility of the MAC to develop the list of primary codes for each Type II AOC. The NCCI contractor shall develop on edit file listing all Type I, II and III CPT and HCPCS codes active in each calendar quarter, indicating in the file the type of each AOC. The contractor shall assist CMS in developing an instruction and/or data file for A/B MACs (MCS practitioner claims) requiring them to deny payment for AOCs listed in column one if one of the primary codes listed in column two, or listed by the MAC when appropriate, is not payable for the same date of service. This instruction will be similar to the Identical Letter issued by CMS in December 1996 to contractors on the same issue but will update the list of AOCs and primary codes.

Since A/B MACs (outpatient hospital services claims) do not currently have edits requiring AOCs to be paid only if an appropriate primary code is also payable, and since MCS edits are implemented at a local level, the NCCI contractor shall incorporate new AOC pairs into the PTP meeting workflow, as indicated, in order to update the AOC files based on revisions to the CPT manual.

The contractor shall update the AOC file annually incorporating annual additions, deletions, and modifications to CPT codes with additional quarterly updates as necessary. The contractor shall use a single integrated NCCI database for incorporating the AOC issues into the PTP WG agendas, and for tracking all codes, corrections, and decisions used to produce the AOC edits and AOC related work products.

The contractor shall assist in testing of the Medicare AOC edit changes on a quarterly basis if changes in the AOC file are made for that quarter. AOC files are usually updated during the fourth quarter as a result of the annual CPT update, with an effective date of January 1st. When required, testing shall take place no later than 1 month prior to the start of the quarter, in order to have the edits go live and be effective in the systems on January 1, April 1, July 1, and October 1 of each year. For each quarterly release, in which there is a data file change, there shall be an electronic test file and electronic final file. (See also Task 16 and Deliverable 3.2.)

On a quarterly basis, the contractor shall produce a corresponding set of test and final AOC edit files for implementation into the Medicaid program. The effective date of Medicaid edits is the same as the due date for the corresponding Medicare MCS practitioner file.

CMS will occasionally require special files for immediate implementation. In those instances, the format will be the same as a format required for quarterly implementation. Such files will be required within 15 days of the latter of the date of request or the date at which all relevant decisions and data have been delivered to the contractor for inclusion in the AOC database.

To assist in the administration of the AOC process, the contractor shall file an Edit Changes Report on the status of AOC edit initiatives on a quarterly basis. The Changes Report shall identify all edits that will change in the Medicare and Medicaid programs for the next quarterly version, including additions, deletions and changes, and categorized by practitioner, hospital and DME subprograms. The contractor shall additionally produce a public reference file of published AOC edit pairs for practitioner, DME supplier and outpatient hospital services for publication on the CMS website. Finally, the contractor shall include AOC activities in its monthly, quarterly and annual Activity Reports to summarize the status of AOC edit initiatives.

Task 8: NCCI Edits Derived from Publications of National Healthcare Organizations and Special Initiatives

The contractor shall review and monitor publications of National Healthcare Organizations (NHOs) to identify potential NCCI edits, including PTP, MUE, AOC or other potential correct coding edits. Publications to be evaluated include but are not limited to the American Medical Association’s CPT Assistant, American Hospital Association’s HCPCS Coding Clinic, coding manuals of NHOs (e.g., American Academy of Orthopedic Surgeons, Society of Interventional Radiology, American College of Radiology), NHO published coding FAQs or guidance, and NHO internet coding FAQs or guidance. The contractor shall identify NCCI edits and edit initiatives to complement currently active NCCI edits. Potential NCCI edits identified through these methodologies will be evaluated, released for review and comment to appropriate NHOs, and implemented through the same process currently utilized for other NCCI edits.

Task 9: NCCI Edit Feedback from National Health Care Organizations

The contractor shall obtain / incorporate feedback about required modifications from the American Medical Association, the American Hospital Association, and other national health care organizations (NHOs). In obtaining feedback, the contractor must utilize the same review and comment process with national health organizations that the contractor currently utilizes for Medicare NCCI (PTP, MUE and AOC) edits. Additionally, the contractor must issue letters to national health care organizations requesting input about how Medicaid PTP / MUE/AOC files should differ from Medicare PTP / MUE/AOC files based on variations in individual State laws and administrative rules. The contractor shall analyze and utilize, when and where appropriate as determined by CPI, input from NHOs on how Medicaid NCCI methodologies should differ from Medicare NCCI methodologies based on variations in individual State laws and administrative rules.

TASK GROUP 3: SUPPORTING OPERATIONS

Task 10: Correspondence and Communications

The contractor shall respond to all correspondence and telephone calls related to the NCCI and all its components, unless indicated otherwise by CMS’ Division of Modeling and Analytics (DMA). All incoming correspondence and outgoing responses will be filed/stored at the contractors’ place of business, and if there is a need for CMS to request any of these documents, contractor shall provide the requested documents to CMS by secure electronic submission within the next 2 business days, unless longer timeframes or alternate delivery means are specified. The contractor shall clearly identify, both within the correspondence and within a correspondence log, whether the issue was related to the Medicare program or the Medicaid program or both. The contractor shall also indicate which subprogram or subprograms (such as PTP, MUE and AOC) and which payment and processing system or systems (FISS, MCS, and VMS) were referenced by the correspondent. For the purpose of this task, correspondence includes all comments, inquiries and requests relative to the implementation of the NCCI program but does not include correspondence related solely to contractor administrative functions such as exchanges related to the task of preparing a file for publication. CMS will provide the contractor with procedures or guidance to assist the contractor in the correct routing of different classes of email for appropriate levels of answer development or clearance.

The contractor shall also be responsible for responding to all inquiries in the NCCI (PTP/MUE) Mailbox, unless indicated otherwise by CMS’ DMA. This mailbox link is referenced on the NCCI PTP/MUE webpage.

The contractor shall review issues identified in correspondence received from physicians, specialty societies, contractors, etc., and make recommendations pertaining to these issues and provide responses to telephone, email, U.S. Mail inquiries, and all other correspondence. Documentation, including copies of incoming correspondence, the contractor's response and, when indicated, references or documents to support that response, shall be provided, as needed.

The contractor shall maintain a comprehensive correspondence log within the integrated NCCI database for incorporating the issues into the NCCI WG agendas, and for tracking all communications used to produce the edits and related work products. The contractor shall manage requests for comment to specialty societies and the responses to those requests as a distinctly identifiable set of correspondence entries within the correspondence functions of the integrated NCCI database. The contractor shall provide CMS with access to the correspondence log when requested.

The contractor shall develop, maintain and provide MACs, states, Medicaid fiscal agents and other responsible parties as determined by CMS with a set of standardized responses to provider inquiries with respect to the existing content, revisions, additions, and/or changes made to the relevant chapters, and index of the NCCI Medicare Coding Policy Manual and the NCCI Medicaid Coding Policy Manual, referenced in Appendix D. The contractor shall maintain and update the standard answers in an electronic format as jointly determined by CMS and the contractor. This sub-task does not require creation of new answers but only the identification of answers to commonly asked questions in order to facilitate the more efficient response to repeat inquiries. An electronic copy of the current standard answers in tabular form shall be appended to the Annual Report. This requirement shall apply to all NCCI programs, currently including the PTP, MUE and AOC, and shall apply to both Medicare and Medicaid programs. Standard answers shall clearly identify the component subprograms to which they refer.

Additionally, the contractor shall provide limited technical support related to NCCI programs for CMS Regional Offices, GAO, OIG, individual states, providers, vendors and other entities when requested and authorized by CMS. Such technical support shall be limited to information, data, processes and skills normally used by the contractor in the performance of tasks defined by this contract.

Task 11: Coding Policy Manual

The contractor shall develop, revise, update, and submit to CMS the National Medicare and Medicaid Correct Coding Initiative Policy Manual (Medicare) and the National Medicare and Medicaid Correct Coding Initiative Policy Manual (Medicaid), collectively referred to herein as the Coding Policy manual and/or any successor documents as defined by CMS, on a regular basis, as needed. Links to these manuals are included in Appendix D. CMS will require separate Medicare and Medicaid manuals or will require a single manual with Medicare and Medicaid differences clearly detailed throughout the manual within the constraints of resources currently allocated to the contract.

The manual or manuals shall apply to all NCCI programs active for Medicare and/or Medicaid, including the PTP, MUE and AOC subprograms. At a minimum, this Manual shall include the policy, e.g., the narrative description or rationale for each CCI edit discussed in the Manual, along with an explanation of the modifiers that can and cannot be used with the codes where applicable. The manual shall address changes in CPT code descriptors, CMS coding policy and units of service decisions, CMS Program Transmittals, CMS Manual instructions, Federal Register notices or other items as directed by CMS.

The contractor shall maintain the Coding Policy Manual providing a final electronic copy of the Manual for publication no later than October 31 of each year. A draft electronic copy of the manual shall be delivered to CMS for review and comment by September 30 of each year. The electronic version shall be provided via email using a word processing format specified by CMS and consistent with CMS standard office systems at the time the copy is provided. The Medicaid content shall specifically address Medicaid services, providers, Federal Medicaid payment policies, and other content relevant to States and Medicaid providers. CMS will require quarterly updates to the manuals with due dates and formats modified to support a quarterly change management process.

Task 12: Correspondence Language Manual

The contractor shall develop, revise, update, and submit to CMS an NCCI Correspondence Manual…