Attachment 1- Draft Statement of Work.docx

SSN 230209 – NCCI

Attachment 1 – Draft Statement of Work

Statement of Work National Correct Coding Initiative

Contents

I. SCOPE

A. Background

The Centers for Medicare & Medicaid Services (CMS) is seeking a contractor to provide support services for the National Correct Coding Initiative (NCCI) program. The NCCI program promotes program integrity (PI) and compliance through guidance, edits, and other methodologies that reduce improper payments in the Medicare and Medicaid program. The NCCI program is administered by the CMS, Center for Program Integrity (CPI). As the largest payer for health care services, the CMS-administered programs are a target for improper payments and schemes to defraud federal health care programs of billions of dollars annually.[footnoteRef:2] Accurate coding and reporting of services by providers and suppliers is a critical aspect of assuring proper payments in Medicare and Medicaid. To address this requirement, CMS developed and implemented the NCCI program to promote national correct coding methodologies and to reduce improper coding that can lead to improper payment in the Medicare and Medicaid programs. In August 1994, CMS awarded the first NCCI contract and NCCI edits have been in place in the CMS claims processing system since January 1, 1996 for Medicare Part B. The NCCI program has since been expanded to include Medicaid under section 6507 of the Patient Protection and Affordable Care Act (PPACA). [2: See the Department of Health and Human Services Agency Financial Report, https://www.hhs.gov/sites/default/files/fy-2021-hhs-agency-financial-report.pdf. ]

The NCCI program includes three types of edits: Procedure to Procedure (PTP), Medically Unlikely Edits (MUEs), and Add-On Code (AOC) edits:

PTP edits - prevent inappropriate payment of services that should not be reported together. Each edit has a Column One and Column Two Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT) code. If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment but the Column Two code is denied unless a clinically appropriate NCCI PTP-associated modifier is also reported.

MUE edits - prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a HCPCS/CPT code is the maximum number of Units of Service (UOS) under most circumstances reportable by the same provider for the same beneficiary on the same date of service.

AOC edits - consist of a listing of HCPCS and CPT AOC with their respective primary codes. An AOC is eligible for payment if and only if one of its primary codes is also eligible for payment.

Claims are denied by NCCI 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. Certain edits also include indicators that may or may not allow the edit to be bypassed with a modifier.

More detailed information about the Medicare and Medicaid NCCI Programs including public documents and edit files, are available at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html and https://www.medicaid.gov/medicaid/program-integrity/national-correct-coding-initiative-medicaid/index.html.

Also, see Appendix C for additional background information.

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 lead to consistent payments to providers in accordance with the payment policies of those programs; and enable CMS and states to meet the Medicaid program requirements as outlined in section 6507 of the PPACA.

CMS seeks a Contractor to achieve the following outcomes through performance of this Statement of Work (SOW):

· Maintain PTP, AOC, and related edits, including updates to current edits with approved recommended changes or comments, and incorporation of CPT and HCPCS additions, deletions, and revisions;

· Maintain MUEs (i.e., units of service edits) to reduce coding and clerical errors, including updates to the current edits with any recommended changes or comments incorporating CPT and HCPCS additions, deletions, and revisions;

· Evaluate clinical and claim information to ensure that NCCI accurately reflects CMS payment and coverage policy decisions; and

· Assist CPI and states to meet the requirements of section 6057 of the PPACA, which expands NCCI methodologies to Medicaid.

The objectives of 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 to prevent improper payments;

Provide continuous maintenance of the NCCI Coding Policy Manuals and the NCCI Correspondence Language Manuals or their successors, and to develop, improve and expand the content and/or format to support the edits and guidelines promulgated by NCCI;

Provide timely and accurate answers to inquiries received from email, correspondence, fax, NCCI 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, and making any necessary corrections upon approval from CMS;

Provide appropriate surveillance of health care coding systems for the purpose of recommending necessary additions, deletions and changes to the NCCI edit programs;

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;

Establish and maintain databases directly accessible to CMS to support deliverables related to the requirements of this contract and 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;

Establish and provide quarterly edit files compatible with CMS requirements for transmission of the data to the claims processing systems; and Establish and provide an audit trail of supporting records to support NCCI Workgroup (WG) decisions and actions for use in responding to queries or other administrative needs.

C. Technical Considerations

The Contractor shall comply with all requirements outlined in this SOW, and shall ensure that all written work (e.g., reports, manuals) are technically correct and meet all applicable statutes, regulations, and HHS and CMS policies relating to communication (i.e established guidelines for grammar, spelling, format, etc). The Contractor shall comply with the following agency specific authorities:

HHS Office of the Secretary Guide to Document Preparation: https://www.hhs.gov/sites/default/files/open/plain-writing/hhs-2014-plain-writing-act-compliance-rpt.pdf Federal Plain Language Guidelines: https://www.plainlanguage.gov/guidelines/

· CMS Brand Strategy and Graphic Standards Guide: https://www.cms.gov/About-CMS/Agency-Information/CMS-Brand-Identity/Downloads/Branding-Guide-August-2017.pdf The COR may provide additional guidance to supplement references listed above.

D. Assumptions and Constraints

The Contractor shall assume the following:

· Assume the workload of this contract will be split between Medicare and Medicaid medical edits, with a heavier workload for Medicare.

· CMS anticipates more than one full-time equivalent may be required to fulfill the Key Personnel role of Medical Director for the Medicare workload.

· CMS anticipates more than one full-time equivalent will be required to fulfill the Key Personnel role of Coding Specialist for both the Medicare and Medicaid workload.

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 SOW.

The Medicare Claims Processing Manual Requirements is a guidance and policy section in the Internet Only Manual (IOM) located in Publication 100-04, Chapter 23, Section 20.9 (National Correct Coding Initiative), which is updated periodically and subject to change at CMS’ request.

Note: The IOM, Publication100-04/Chapter 12/Section 30, is a related publication to the NCCI Program, owned by the Center for Medicare (CM). This chapter is entitled Correct Coding Policy, which sets principles to promote correct coding in Part B claims.

A. General Requirements

The NCCI Contractor shall accomplish the objectives outlined in Section I.B by performing the tasks listed below. The intent of this SOW is to capture all the work currently being performed by the NCCI program while providing flexibility for future enhancements and improvements.

1. Security

NCCI Work Product Confidentiality: To ensure the confidentiality of pre-decisional and/or unpublished NCCI work product, the Contractor shall not enter into any contractual arrangements pertaining to the NCCI program, its processes, or its work products during the period of performance of this contract with any private or public entity external to the Government without the express permission of CMS. Outside of the performance of the tasks specified in this SOW, the Contractor shall not discuss, reveal or otherwise make available any NCCI edits, lists, files, decisions, discussions, guidance or other work product or internal documents without the express permission of CMS. The Contractor shall be bound by the confidentiality restrictions associated with the American Medical Association's (AMA) CPT codes in addition to these Confidentiality and Conflict of Interest requirements of this contract. The Contractor shall not release to any entity not directly involved in this contract the code or modifier numbers or descriptors of any CPT code or HCPCS code not already published by the AMA or by CMS in the Federal Register. The Contractor shall require its owners, employees and subcontractors to be bound by all Confidentiality and Intellectual Property requirements contained in this contract.

The Contractor shall follow all CMS policies and guidelines to secure any private data or information, including protected health information (PHI) and personal identifiable information (PII), that may result during the course of this contract. For information related to CMS Information Security and Privacy, please reference the following link: https://www.cms.gov/research-statistics-data-and-systems/cms-information-technology/informationsecurity. For baseline information security requirements, see SOW Attachment A.1 Information Security Requirements.

2. Section 508- Accessibility of Electronic and Information Technology

Please refer to Appendix D of the SOW for 508- Accessibility of Electronic and Infomration Technology guidelines.

B. Tasks

This SOW focuses on the following six areas:

Task Group 1: Contract Management Task Group 2: Core Operations Task Group 3: Support Operations Task Group 4: Reports Management Task Group 5: State and Third-Party Adoption Coordination Task Group 6: Closeout Operations

In the following sections, each task is described through a set of subtasks that delineate expected efforts associated with CMS requirements and deliverables.

TASK GROUP 1: CONTRACT MANAGEMENT

Task 1.0 Kick-Off Meeting

The Contractor shall participate in a kick-off meeting with CMS 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, which will be held virtually.

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

Introduction of key personnel Overview of the technical approach Draft Onboarding Plan Draft Project Management Plan (PMP) Other topics as directed by CMS.

Note: There will be a sixty calendar day transition period beginning at the contract start date between the outgoing Contractor and the incoming Contractor. Refer to Task 1.3.

Task 1.1 Project Management Plan

The draft PMP is due at the kick-off meeting. The Contractor shall prepare and submit to CMS a detailed final PMP within 60 days of the contract start date .

The Contactor shall update the PMP throughout the period of performance if any significant information in the PMP changes and immediately submit a copy to the CMS COR. The PMP shall also be updated as necessary to include any projects (special deliverables) undertaken by the Contractor, with a copy to the COR.

. The PMP shall include, at a minimum the following information:

· Each Task and each step of its implementation (including all reports, deliverables, and projects)

· Project organization

· Key milestones signifying successful completion of each task

· Periodic internal assessment/progress reports planned

· Description on how the Contractor intends to use medical specialty societies and others in advisory capacity with regard to proposed edits

Task 1.2 Onboarding Plan

The Onboarding Plan includes the steps that the Contractor plans to take to successfully assume the operational work of this contract. At a minimum, this Onboarding Plan shall specifically detail the steps (with dates) illustrating how all the NCCI functions outlined in this contract shall be transitioned to the Contractor. The Onboarding Plan shall include all the necessary information broken out by project phases (i.e., preparation, transfer, and fully operational) and workload. The Onboarding Plan shall also illustrate how the Contractor will receive background information, documentation and records and priority tasks for start-up from CMS and the incumbent Contractor. The Onboarding Plan shall demonstrate how the Contractor will assume responsibility for operations as of the contract start date, and describe how those operations will be initiated and rapidly brought up to full performance levels. The draft Onboarding Plan shall be 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 calendar days after the kick-off meeting.

The Contractor shall include a management approach to Onboarding within the Onboarding Plan, which will ensure communication, cooperation, consultation, and coordination between the Contractor, CMS and the outgoing contractor are maintained. The Contractor shall present and provide written weekly status reports to CMS. .

Task 1.3 Transition Out Management Plan (optional)

The Contractor shall develop a Transition Management Plan to outline the steps and tasks that will be required to successfully transfer the work of this contract to a new contractor. The Contractor shall provide a draft Transition Out Management Plan no later than sixty calendar days prior to the end of the contract. The Contractor shall provide a final Transition Out Management Plan no later than sixty days prior to the end of the contract

At a minimum, the Transition Out Management Plan shall address the Contractors approach to the following:

· Planning

· Description of transition activities

· Transition schedule, including key milestone events and migration activities led by the Contractor

· How deliverables will be managed during the transition

· Plan of action to maintain output of ongoing work through transition period while working with incoming Contractor(s)

· List of all documents and how documents will be maintained or destroyed in accordance with the National Archives and Records Administration and CMS processes

· Transfer

· Transition deliverables, including updated inventory lists and updated deliverables list

· Transfer of and access to in-process deliverables and work products

· Transfer of licenses and warranties, if applicable

· Coordination Transition meetings, as necessary, with the incoming Contractor(s)

· Communications and reporting during the transition period

· Risks and issue mitigation

· Inventory management of Personally Identifiable Information (PII), Government Furnished Equipment (GFE), and Contractor-owned resources

· Other information deemed necessary by the Contractor or requested by CMS

· Development

· Training for incoming Contractor on Medicare and Medicaid NCCI PTP/MUE/AOC Program deliverables

· WG Agendas – Topics, Documents, Materials, Resources, etc. for weekly edit discussions

· WG Decisions - How edits are determined and decisions made. The process, documents, edit recording/sign-off document, edit criteria, medical professionals involved, etc.

· Edit Files (Test & Final) and Change Reports – Detailed and extensive training on the overall process of the quarterly edit file deliverables for edit file preparation, file development, file creation, maintenance, including the GENTRAN process or transfer of files for the Medicare Administrative Contractors (MACs), posting to CMS public webpages or websites, etc.

· Monthly & Quarterly Reports - preparation, development, contents, etc.

· Coding Policy Manual (Draft & Final) - preparation, development, contents, updates, maintenance, etc.

· Correspondence Language Manual (Draft & Final) - preparation, development, contents, updates, maintenance, etc.

· Technical Guidance Manual (Draft & Final) - preparation, development, contents, updates, maintenance, etc.

· IOM – contents, updates, etc.

· Education to Providers – explain process and necessary materials, etc.

· Annual Activity Report – preparation, development, contents, etc.

· Contract Year Report - preparation, development, contents, etc.

· NCCI Edit Databases sent quarterly to CMS – preparation, development, contents, updates, maintenance, etc.

· Delineation of work

· Ongoing Work

· How the Contractor will respond to inquiries until the end of the designated transition period

· How the Contractor will receive and forward documentation to the incoming Contractor through the end of the designated transition period

· Contract End

· All transition activities must be concluded by the completion of the sixty day transition out period.

TASK GROUP 2: CORE OPERATIONS

Task 2.0 Procedure-to-Procedure Edits

The NCCI PTP edits are 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. Medicare and Medicaid PTP edits are effective for the practitioner (i.e., Multi-Carrier System (MCS)), outpatient hospital (i.e., Fiscal Intermediary Shared System (FISS) – for Part A MACs) and Durable Medical Equipment (DME) (i.e., ViPS Medicare Shared System (VMS)) claims processing systems.

The NCCI Contractor shall develop PTP edit files in a format jointly agreed to and approved by CMS. The Contractor shall be responsible for maintaining and updating the NCCI PTP edits/code pairs identified as a result of the CPT and HCPCS code updates. The AMA updates the CPT CodeBook once annually, with new editions effective January 1st of each year, and updates some CPT code sections more frequently. The HCPCS code system is updated quarterly (https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update).

The Contractor shall maintain and update the PTPs based on the most up to date resource available. The Contractor shall also identify, develop, propose, and maintain PTP edits using the CPT, HCPCS, and current public CMS policies, such as final payment rules published in the Federal Register, the CMS Online Manual System, and jurisdiction-specific policies, such as local coverage determinations, etc. The Contractor shall proactively analyze claims data for the assessment of new proposals and the reassessment of previously released PTP edits. The Contractor shall simultaneously consider the PTP edits as a whole and review articles, fraud reports, correspondence and/or other information sources to identify areas of Medicare and Medicaid overpayments and to propose new PTP edits, new types of edits or new NCCI programs to reduce fraud, waste and abuse and promote consistent payment to providers.

The Contractor shall use claim data from CMS or CMS' data Contractor, extract the relevant information, summarize the data for each HCPCS/CPT code pair and provider/supplier type, and create user-friendly reports for review of PTP issues with CMS in WG teleconferences/virtual meetings.

The Contractor shall update edits/code pairs on a continual basis using regular CMS NCCI-PTP Workgroup (hereafter referred to as “WG”) meetings with CMS. The Contractor is responsible for supporting the WG to proactively and reactively re-evaluate the existing PTP edits and edit program, implement changes based on decisions of the WG, maintain records of the WG activity and WG decisions, produce edit files and public reports, and assist in the testing of the edit files. The Contractor shall provide administrative support for CMS’ WG by developing the agenda; preparing data, proposals, and reconsideration requests; maintaining a record of WG proceedings; organizing decisions and updating files and correspondence in response; tracking inquiries, responding to FOIA requests, retrieving signed decisions, setting up meetings with outside parties at the direction of CMS; and providing any additional support as required by the WG. WG meetings will occur at least weekly.

The Contractor shall identify relevant National Healthcare Organizations (NHOs) such as the AMA, specialty societies, CMS components, contractor/MAC medical directors, and other individuals or organizations as directed by CMS, and circulate proposed edits and edit changes to those entities for comment, using a confidential process agreed to by CMS. 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 reevaluate 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 and present the position proposed by the petitioner, a contrary position in order to create a balanced presentation, data to support a decision, and 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 databases for producing and tracking all codes, corrections, and decisions used to produce PTP edits as well as PTP-related work products, such as the NCCI Coding Policy Manual and meeting agendas. The Contractor shall also maintain an electronic log of provider inquiries and associated answers regarding NCCI Coding Policy Manual changes. CMS and the Contractor shall expand the NCCI databases 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 NCCI Coding Manual text, to reduce Contractor and CMS effort. The Contractor shall provide CMS with continuous controlled access to the NCCI databases and the instructions for using it. It would, for example, be acceptable for the integrated NCCI databases to consist of the Microsoft ACCESS databases made available to CMS. 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 one month prior to the end of the quarter in order to have the edits go live and be effective in the systems on the first day of each calendar quarter (i.e., January 1, April 1, July 1, and October 1) of each year. For each quarterly release, the Contractor shall produce electronic test files and electronic final files.

PTP Effective Dates:

· The effective date of the MCS (Practitioner), FISS (Outpatient Hospital/Outpatient Code Editor (OCE)), and VMS (DME) files is the first day of each quarter (i.e., January 1, April 1, July 1, and October 1) of each year.

PTP Qaurterly Release Due Dates:

· Quarter 1:All PTP files (MCS, FISS (OCE) and VMS) are due on the same date to CMS.

· Quarter 2, 3 & 4: The PTP FISS (OCE) edit files are due to CMS earlier than the MCS and VMS files.

· All due dates are specified in the deliverables schedule (Appendix A and Appendix B).

Medicaid PTP Effective Dates & Quarterly Release Due Dates:

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 are the same as the due dates for the corresponding Medicare MC practitioner file.

CMS will, at times, require special files for immediate implementation (e.g., ad hoc replacement edit files, “emergency” replacement files). In those instances, the format will be the same as the format required for quarterly implementation. Such files will be required within fifteen calendar 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 NCCI databases.

Prior to submission of the quarterly and/or ad hoc replacement edit files, the Contractor shall ensure all information submitted has undergone quality assurance reviews to ensure accurate and error-free edit files.

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

Task 2.1 Medically Unlikely Edits (MUE)

The NCCI MUE program produces edits in which a service or code (claim line) is denied if the UOS for the code exceed the MUE value for a specified range, such as a claim line or date of service. The Contractor is responsible for supporting the CMS NCCI-MUE WG (hereafter referred to as “WG”) to proactively and reactively evaluate the existing MUEs and edit programs, implement changes based on decisions of the WG, maintain records of the WG activity and WG decisions, produce edit files and public reports, and assist in the testing of the edit files.

The NCCI Contractor shall develop MUE edit files in a format jointly agreed to and approved by CMS. The Contractor shall maintain and update the MUEs identified as a result of the CPT and HCPS code updates. The AMA updates the CPT CodeBook annually, with new editions effective January 1st of each year, and updates some CPT code sections more frequently. The HCPCS code system is updated quarterly (https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update).

The Contractor shall maintain and update MUEs based on the most up to date resources available. The Contractor shall also identify, develop, propose, and maintain MUEs using CPT, HCPCS, and current public CMS policies, such as final payment rules published in the Federal Register, the CMS Online Manual System, and jurisdiction-specific policies, such as local coverage determinations, etc. The Contractor shall proactively analyze claims data for the assessment of new proposals and reassessment of previously released MUEs. The Contractor shall use claims data from CMS or its data Contractor, extract the relevant information, summarize the data for each HCPCS/CPT code and provider/supplier type, and create user-friendly reports for review of MUE issues with CMS in WG teleconferences/virtual meetings. 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 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’ 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 identify relevant NHOs using such resources as the AMA, specialty societies, CMS components, contractor/MAC medical directors, and other individuals or organizations, 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 reevaluate existing MUEs in response to requests for reconsideration by specialty societies; government entities, including CMS and states; 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 databases for producing, tracking all codes, corrections, and decisions used to produce the MUEs and MUE related work products and documenting agendas. The NCCI databases shall be used to support the MUE WG in the same fashion that it is used to support the PTP WG. The Contractor shall also maintain an electronic log of provider inquiries and associated answers regarding NCCI Coding Policy Manual changes.

The Contractor shall assist in testing of the Medicare edit changes on a quarterly basis. Testing shall take place no later than one month prior to the end of the quarter in order to have the edits go live and be effective in the systems on the first calendar day of each quarter (i.e., 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.

MUE Effective Dates:

· The practitioner (MCS), Outpatient Hospital (OPH) (FISS), and DME (VMS) files are effective the first day of each quarter.

MUE Qaurterly Release Due Dates:

· All quarterly release files (FISS/OCE, MCS and VMS) have the same due dates to CMS.

· All due dates are specified in the deliverables schedule (Appendix A and Appendix B).

Medicaid MUE Effective Dates & Quarterly Release Due Dates:

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 Medicare 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.

Prior to submission of the any MUEs, the Contractor shall ensure all information submitted has undergone quality assurance reviews to ensure accurate and error free edit files.

CMS will, at times, require special files for immediate implementation (e.g., “emergency” replacement files). In those instances, the format will be the same as a format required for quarterly implementation. Such files will be required within fifteen calendar 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 NCCI databases.

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 2.2 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. MUEs shall be developed for HCPCS J codes for drugs and drug-related HCPCS, and for HCPCS C and Q codes, as part of the NCCI 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 maintain and update MUEs based on the most up to date resources available. The Contractor shall also identify, develop, propose, and maintain this subset of MUEs using HCPCS, and current public CMS policies, such as final payment rules published in the Federal Register, the CMS Online Manual System, and jurisdiction-specific policies, such as local coverage determinations, etc.

The Contractor shall incorporate this process into the ongoing development of MUEs for other new and modified HCPCS/CPT codes. The Contractor shall use the MUE review-and-comment process to allow 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 MUE WG to review, assign and implement the MUEs, integrating them into the current MUE files. The Contractor shall 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 use claims data from CMS MUE WG or its data Contractor, extract the relevant information, summarize the data for each HCPCS/CPT code and provider/supplier type, and create user-friendly reports for review of MUE issues with CMS MUE WG in teleconferences/virtual meetings.

Because MUEs for these codes may differ between DME supplier and practitioner claims, the Contractor shall develop, if required, separate MUEs for the practitioner (PRA) 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 (e.g., PTP, MUE and AOC).

Task 2.3 Add-On Code (AOC) Edits

The NCCI AOC program produces edits based on code pairs in which the add-on code is not payable unless the primary code is present on the same date of service. The Contractor shall maintain and update AOC edits based on the most up to date resources available. The Contractor shall also identify, develop, propose, and maintain AOC edits using CPT, HCPCS, and current public CMS policies, such as final payment rules published in the Federal Register, the CMS Online Manual System, etc. 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 evaluate the existing AOC edits and edit program, implement changes based on decisions of the WG, maintain records of the WG activity and WG decisions, produce all edit files and public reports, and assist in the testing of the edit files. The Contractor shall ensure that this task is fully integrated into the support of the NCCI-PTP WG, the integrated NCCI databases that house the necessary information to enable that integration, and 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, as well as evaluate any HCPCS Level II codes for AOCs or primary codes. These codes should be divided into three groups:

· Type I AOCs are codes for which the CPT specifically identifies all the primary codes with which these codes shall be reported. For Type I AOCs, all primary codes are determined by CMS.

· Type II AOCs are codes for which the CPT 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.

· Type III AOCs are those for which the CPT 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 AOC edit files in a format jointly agreed to and approved by CMS. The NCCI Contractor shall develop edit file(s) listing all Type I, II and III(also referred to as Type 1, 2, and 3) 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 both A/B MACs (MCS practitioner claims) and I/OCE Contractor (FISS outpatient hospital claims) or other claims as deemed appropriate by CMS, for AOC edits.

The NCCI Contractor shall incorporate new AOC pairs into the PTP WG meeting workflow, as indicated, to update the AOC files based on revisions to CPT and HCPCS Level II codes. The Contractor shall update the edits using the most recent HCPCS updates, which are published on a quarterly basis.

The Contractor shall update the AOC file annually incorporating annual additions, deletions, and modifications to CPT codes and HCPCS codes. The Contractor shall provide quarterly updates and replacement files as necessary, incorporating other additions, deletions, and modifications to CPT codes and HCPCS codes. The Contractor shall use the integrated NCCI databases for incorporating the AOC issues into the NCCI-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 maintain and update AOCs based on the most recent data/information available.

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 sixty calendar days prior to the start of the quarter, in order to have the edits go live and be effective in the systems on the first calendar day of each quarter (i.e., January 1, April 1, July 1, and October 1) of each year. For each quarterly release, in which there is an edit file change, the Contractor shall produce an electronic test file and electronic final file.

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 (e.g., “emergency” replacement files). In those instances, the format will be the same as a format required for quarterly implementation. Such files will be required within fifteen calendar 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 NCCI databases.

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 Edit 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. The files shall include all data elements necessary to implement the AOC edits in Medicare standard systems for that quarter. Finally, the Contractor shall include AOC activities in its monthly, and annual Activity Reports to summarize the status of AOC edit initiatives.

Task 2.4 NCCI Edits Derived from Publications and Special Initiatives

The Contractor shall review and monitor publications to identify potential NCCI edits, including PTP, MUE, AOC or other potential correct coding edits. The Contractor shall identify NCCI edits and edit initiatives to complement currently active NCCI edits. The Contractor shall maintain and update NCCI edits based on the most recent data/information available (e.g., final payment rules published in the Federal Register). The Contractor shall propose NCCI edits that will be evaluated, released for review and comment to appropriate NHOs, and implemented through the same process currently used for other NCCI edits.

Task 2.5 NCCI Edit Feedback from National Health Care Organizations and the States

In accordance with a process agreed to by CMS, the Contractor shall obtain/incorporate feedback from the AMA, the American Hospital Association, other NHOs, and the states, about proposed Medicare and Medicaid NCCI edits, as appropriate. The Contractor may propose improvements/innovations to the process, subject to approval by CMS.

Additionally, the Contractor shall issue letters to NHOs and states specifically requesting input about how Medicaid PTP/MUE/AOC edits should differ from Medicare PTP/MUE/AOC edits based on variations in individual State laws and administrative rules. The Contractor shall also analyze and use, when and where appropriate as determined by CMS, input from NHOs and the States on how Medicaid NCCI methodologies should differ from Medicare NCCI methodologies based on variations in individual State laws and administrative rules.

TASK GROUP 3: SUPPORT OPERATIONS

Task 3.0 Correspondence, Inquiries and Communications

The Contractor shall respond timely to all correspondence, inquiries and communications related to the NCCI Program and all of its components, unless indicated otherwise by CMS. For the purpose of this task, correspondence includes all comments, inquiries and requests relative to the implementation of the NCCI program, including correspondence related solely to the Contractor’s administrative functions, such as exchanges related to the task of preparing a file for publication. For the purpose of inquiries, timely means that the NCCI Contractor shall respond to inquirers by acknowledging receipt of the inquiry within two business days of receipt and to issue a response within thirty calendar days of receipt. The NCCI Contractor shall notify the CMS workgroup of inquiries that have not received a substantive response within thirty calendar days from receipt.

All incoming correspondence and outgoing responses shall be filed or stored electronically by the Contractor. The Contractor shall provide these documents to CMS, upon request, by secure electronic submission within the next two business days, unless longer timeframes or alternate delivery options are specified. The Contractor shall clearly identify, both within the correspondence and within a correspondence log, whether the issue was related to the Medicare or Medicaid program, or both. The Contractor shall also indicate which subprogram(s) (i.e., PTP, MUE and AOC) and which payment and processing system or systems (FISS, MCS, and VMS) were referenced by the correspondent. CMS will provide the Contractor with procedures or guidance to assist the Contractor in the correct routing of different categories of email for appropriate levels of answer development or clearance.

The Contractor shall also be responsible for responding to all inquiries in the NCCI Resource Mailbox, unless indicated otherwise by CMS. This mailbox link is referenced on the NCCI webpages.

The Contractor shall review and provide timely responses to all issues identified in correspondence and inquiries received from physicians, AMA, NHOs, specialty societies, contractors, public, etc., making recommendations pertaining to these issues via email, fax, or U.S. Mail. Documentation, including copies of incoming correspondence, the Contractor's response and, when indicated, references or documents to support that response, shall be provided, as requested by CMS. The Contractor shall not respond to media inquiries other than to notify the inquirer that they may submit a Media Inquiry Form. The Contractor shall inform CMS’ CPI/Audits and Vulnerabilities Group (AVG) of any media inquiries.

The Contractor shall maintain a comprehensive correspondence log within the integrated NCCI databases for incorporating the issues into the NCCI WG agendas timely, and for tracking all communications used to produce the edits and related work products. The Contractor shall manage requests timely for comments 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 databases. The Contractor shall provide CMS with access to the correspondence log.

The Contractor shall maintain and update the current set of CMS approved standardized responses (e.g., correspondence response template language) to inquiries. The Contractor shall maintain and update the standardized responses in an electronic format as jointly determined by CMS and the Contractor. This sub-task does not require the proactive creation of new answers but only the identification of answers to commonly asked questions in order to facilitate a more efficient response to repeat inquiries as directed and approved by the WG. An electronic copy of the current standardized responses in tabular form shall be appended to the Contract Year Report and have the same deliverable due date as the Contract Year Report.