CMS Sources Sought and Draft SOW: National Correct Coding Initiative

Notice ID 230209

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.

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