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Medicaid NCCI edits: how the Medicaid tables differ from Medicare's

State Medicaid programs run the National Correct Coding Initiative too, but from their own edit files. Comparing the 2026 Q4 Medicaid NCCI files with the Medicare tables of the same quarter pair by pair and code by code: the Medicaid practitioner table holds 1,825,786 procedure-to-procedure pairs against Medicare's 1,732,820, the outpatient hospital table 1,505,274 against 1,406,699, and Medicaid adds a durable medical equipment pair table of 43,690 pairs that Medicare does not publish. Medically Unlikely Edit values differ for 2,461 practitioner codes, and the Medicaid MUE tables carry no adjudication indicator. Below, each difference is counted from the CMS files, with example pairs you can open in the checker.

Compiled from CMS files by the QuickIntell RCM Editorial Team · Data effective · Method: reference methodology · Report a data correction

Data currency: Medicaid NCCI edit files: 2026 Q4 (effective October 1, 2026); NCCI PTP edits: v323r0 (2026 Q4) (effective October 1, 2026); NCCI MUE tables: 2026 Q4 (effective October 1, 2026). Next CMS release: January 1, 2027 (quarterly update).

Medicaid-only practitioner pairs
93,598
outpatient hospital: 99,330
Medicare pairs Medicaid omits
632
outpatient hospital: 755
Modifier indicator differences
1,829
practitioner; 1,783 allow a modifier in Medicaid only
Medicaid DME pair table
43,690
1,188 column-1 codes; Medicare has no DME table
Practitioner MUEs higher in Medicaid
2,451
10 lower, 12,431 the same
Outpatient MUEs set to 0 as inpatient procedures
1,293
Medicaid outpatient hospital table

Why Medicaid has its own NCCI files

Section 6507 of the Affordable Care Act required state Medicaid programs to use NCCI methodologies, and the Medicaid edits start on October 1, 2010: a pair that Medicare has applied since 1996 carries a Medicaid effective date of 2010 or later. The Medicaid edits follow the NCCI methodology but form a separate program with its own quarterly files, one PTP table and one MUE table each for practitioner services, outpatient hospital services and durable medical equipment. The files posted on the CMS Medicaid NCCI page open with a warning that they should not be used by state Medicaid programs as their edit file.

The reason is how the program is administered. According to the CMS note on the Medicaid NCCI edit change report files, CMS posts the complete quarterly files for state Medicaid agencies on the Medicaid Integrity Institute's RISSNET portal, and each quarter's files replace the previous ones in full. A state that finds an edit in conflict with its laws, regulations, administrative rules or payment policies can ask CMS to deactivate it, following the Medicaid NCCI Technical Guidance Manual, and CMS applies approved deactivations to the complete set of edits each quarter. CMS also publishes a quarterly change report of additions, deletions and indicator changes, summarized in the Medicaid section of the NCCI 2026 Q4 changes report. The national files below are therefore the baseline every state starts from, not a promise of what a given state pays.

Procedure-to-procedure pairs: Medicaid against Medicare

Each row compares one setting's active pairs, matched on the column-1 and column-2 codes. A shared pair can still differ in its modifier indicator, its rationale label or its effective date; the counts below come from the 2026 Q4 files effective 2026-10-01.

Active PTP pairs, Medicaid NCCI and Medicare NCCI, 2026 Q4
MeasurePractitionerOutpatient hospital
Medicare active pairs1,732,8201,406,699
Medicaid active pairs1,825,7861,505,274
Pairs only in Medicaid93,59899,330
Medicare pairs Medicaid does not carry632755
Indicator 0 in Medicare, 1 in Medicaid1,783715
Indicator 1 in Medicare, 0 in Medicaid46757
Shared pairs with a different rationale label18,84317,931
Pairs that allow a modifier (Medicaid)69%95%
Pairs that allow a modifier (Medicare)70%96%

Where the extra Medicaid pairs are

Most Medicaid-only pairs fall in code groups Medicare seldom edits on these claims. K codes (15,519), L codes (15,141) and E codes (9,488) lead the practitioner column-1 counts: durable medical equipment, orthotic and prosthetic items that Medicare pays through DME suppliers (its practitioner MUE for most of them is 0, as the MUE section shows), while Medicaid allows them on practitioner claims and edits them there. The rest spread across the CPT ranges, led by 10000-19999 (8,927) and 20000-29999 (8,779). 79,500 of the 93,598 practitioner-only pairs (85%) carry effective dates in 2012, 2013 and 2015, and 64% of them allow no modifier, against 31% across the whole Medicaid practitioner table.

Medicaid-only PTP pairs by column-1 code group, 2026 Q4
Column-1 code groupPractitionerOutpatient hospital
K codes: temporary DME codes15,51915,519
L codes: orthotics and prosthetics15,14115,141
E codes: durable medical equipment9,4889,488
CPT 10000-199998,9277,792
CPT 20000-299998,77911,704
CPT 60000-699997,9796,693
CPT 00100-019995,9536,486
CPT 30000-399995,6417,278
CPT 90000-999993,7924,697
CPT 40000-499993,6785,192
Top groups of 93,598 practitioner and 99,330 outpatient hospital Medicaid-only pairs. CPT ranges are shown as numbers; HCPCS Level II groups use the CMS section names.

The column-1 codes with the most Medicaid-only practitioner pairs are K0808 (284 pairs, Power operated vehicle, group 2 very heavy duty, patient weight capacity 451 to 600 pounds), K0802 (283 pairs, Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds), K0807 (282 pairs, Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 pounds), K0801 (281 pairs, Power operated vehicle, group 1 heavy duty, patient weight capacity 301 to 450 pounds) and K0806 (280 pairs, Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds). Pairs run in the other direction too: Medicare carries 632 practitioner pairs and 755 outpatient hospital pairs that the Medicaid tables leave out, most with a column-1 code in CPT 30000-39999 or G codes: procedures and professional services.

Modifier indicators that differ

In the practitioner tables 1,783 shared pairs carry indicator 0 in Medicare but indicator 1 in Medicaid, so an NCCI-associated modifier can separate them only on a Medicaid claim, and 46 go the other way. The relaxed pairs concentrate on a few column-2 codes: 94761 (399 pairs), 94760 (395 pairs), 64491 (96 pairs) and 64492 (96 pairs). In the outpatient hospital tables the balance is closer, 715 relaxed against 757 tightened, and the tightened pairs cluster on 93355, 33210 and 33211 as column-2 codes. A claim that clears a Medicare edit with modifier 59 or an X modifier can therefore still deny on Medicaid, and the reverse.

Computed from the 2026 Q4 stores when this page was built. Open a pair to run it in the checker with the Medicaid table selected; the checker also states the Medicare answer.

Example practitioner pairs answered from both programs' tables
PairMedicareMedicaidMedicaid rationale
11922 + 96374No edit96374 into 11922, indicator 1Standards of medical/surgical practice
44203 + 44602No edit44602 into 44203, indicator 1Standards of medical/surgical practice
63621 + 77336No edit77336 into 63621, indicator 0CPT Manual or CMS manual coding instruction
00145 + 6970669706 into 00145, indicator 1No edit—
20553 + 6449564495 into 20553, indicator 120553 into 64495, indicator 1More extensive procedure
00100 + 9476094760 into 00100, indicator 094760 into 00100, indicator 1Standard preparation/monitoring services for anesthesia
00472 + 9476094760 into 00472, indicator 094760 into 00472, indicator 1Standard preparation/monitoring services for anesthesia

The Medicaid DME pair table

Medicare edits durable medical equipment claims with MUEs but publishes no procedure-to-procedure table for them. Medicaid does: its DME table holds 43,690 active pairs over 1,188 column-1 codes, and 72% of them allow no modifier, far more than the 31% in the Medicaid practitioner table. Two rationales account for most of it: "Mutually exclusive procedures" (22,506 pairs) and "More extensive procedure" (14,281 pairs), which is how the table stops two versions of the same item, or an item and the larger item that includes it, from being billed together. By column-1 code the table is mostly K codes (15,519), L codes (15,141) and E codes (9,464). Every one of its pairs also appears in the Medicaid practitioner and outpatient hospital tables, where the DME pairs make up 47% of the 93,598 Medicaid-only practitioner pairs. In the checker, choose Medicaid and the DME setting.

Example pairs from the Medicaid DME table, 2026 Q4
PairMedicaid DME answerRationaleEffective
29000 + 2901029010 into 29000, indicator 0Mutually exclusive procedures2013-04-01
E0295 + E0250E0250 into E0295, indicator 0Mutually exclusive procedures2014-01-01
E1085 + E1220E1220 into E1085, indicator 0Mutually exclusive procedures2012-10-01
E1171 + E2370E2370 into E1171, indicator 0More extensive procedure2012-10-01

Medically Unlikely Edits: Medicaid against Medicare

Codes with a published MUE in each program's 2026 Q4 tables, matched by code within each setting. Higher and lower compare the Medicaid value with the Medicare value for codes both programs publish. ADA dental codes in the Medicaid tables (117 rows) are left out.

MUE values by setting, Medicaid NCCI and Medicare NCCI, 2026 Q4
MeasurePractitionerOutpatient hospitalDME supplier
Codes with a Medicaid MUE15,33415,3302,788
Codes with a Medicare MUE15,14315,0933,109
Same value12,43112,1662,115
Medicaid higher2,4511,353267
Medicaid lower101,317110
Only in Medicaid442494296
Only in Medicare251257617
Medicare 0, Medicaid above 02,3471,133234

The practitioner table shows the clearest pattern. Medicare sets a practitioner MUE of 0 for 2,639 codes, mostly supplies, equipment, orthotics and prosthetics that Medicare pays through DME suppliers rather than on practitioner claims, and Medicaid allows units for 2,347 of them: 2,347 of the 2,451 higher Medicaid values are codes Medicare sets to 0 for practitioners. Only 10 practitioner codes have a lower Medicaid limit. The outpatient hospital table runs the other way: 1,293 codes carry the Medicaid rationale "Inpatient Procedure" with an MUE of 0, while Medicare allows one unit for 1,196 of them, which accounts for most of the 1,317 lower facility values. Codes with a practitioner MUE only in the Medicaid tables are led by S codes (185), A codes (73) and H codes (68); S and H codes are HCPCS sets that Medicare does not pay (S codes serve private payers and Medicaid programs and H codes were created for state Medicaid agencies to report mental health, alcohol and drug treatment services).

The Medicaid tables also label their reasons differently. They carry no adjudication indicator, so a Medicaid MUE does not say whether it is tested per claim line or per date of service, and several rationale labels appear only in Medicaid: "Clinical: Medicaid Data", "Clinical: Medicare Data" and "Inpatient Procedure". Medicare labels such as "Compounded Drug Policy", "Oral Medication; Not Payable" and "Published Contractor Policy" do not occur in the Medicaid files. The MUE lookup with the Medicaid setting shows both values side by side for any code.

The codes whose Medicaid practitioner MUE is furthest above or below the Medicare value. HCPCS Level II codes show the CMS descriptor; CPT codes are shown as numbers.

Largest practitioner MUE differences, 2026 Q4
CodeHCPCS descriptorMedicareMedicaidMedicaid rationale
J7508Tacrolimus, extended release, (astagraf xl), oral, 0.1 mg0300CMS Policy
J7512Prednisone, immediate release or delayed release, oral, 1 mg0300Prescribing Information
A4624Tracheal suction catheter, any type other than closed system, each0270CMS Policy
B5200Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids-freamine-hbc-premix0225Prescribing Information
A5120Skin barrier, wipes or swabs, each15050CMS Policy
A5056Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each9040CMS Policy
A5057Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each9040CMS Policy
A7525Tracheostomy mask, each83Clinical: Medicare Data

Checking a Medicaid claim

The NCCI checker with the Medicaid table answers any pair from the national Medicaid files for practitioner, outpatient hospital or DME claims and states the Medicare answer for the same pair, which is useful for dual-eligible patients and for practices that bill both programs. Add a date of service from 2024-01-01 to 2026-12-31 to leave out edits that took effect later and to keep edits CMS has deleted since, up to their deletion date; Medicaid keeps 31,381 practitioner pairs deleted in that window and Medicare 29,220. Before appealing a denial, confirm the edit with the state Medicaid agency or the managed care plan, because a state may have deactivated it and plans can add their own edits.

Medicaid unit limits are in the Medicaid MUE lookup, and the Medicare side of every figure on this page is explained on the NCCI edits reference hub, with the coding principles behind both programs in the NCCI Policy Manual guide. HCPCS drug code pages note where a drug's Medicaid MUE differs from its Medicare value (47 drug codes in 2026 Q4).

Where QuickIntell fits on Medicaid claims

Medicaid and Medicare can bundle the same pair differently, and states can switch edits off. QuickCode supports qualified coder review before the billing handoff, where the payer's own edits are applied to the whole claim, and QuickRCM works the edit-driven Medicaid and Medicare denials that still get through, with human review.

See QuickCode for payer-specific coder reviewSee QuickRCM for Medicaid denial follow-upBook a meeting

Frequently asked questions

Are Medicaid NCCI edits the same as Medicare NCCI edits?

No. They follow the same methodology, but CMS maintains separate Medicaid edit files. In the 2026 Q4 practitioner tables Medicaid carries 93,598 pairs that Medicare does not, Medicare carries 632 that Medicaid does not, and 1,829 shared pairs have a different modifier indicator. Medicaid also publishes a DME pair table, which Medicare does not, and its MUE values differ for 2,461 practitioner codes.

Why does the CMS Medicaid file say it should not be used by states?

The public files are posted for reference. According to the CMS note on the Medicaid NCCI edit change report files, CMS posts the complete quarterly edit files for state Medicaid agencies on the Medicaid Integrity Institute's RISSNET portal, each set replacing the prior quarter in full, and a state may ask CMS to deactivate an edit that conflicts with its laws, regulations, administrative rules or payment policies. The edits a state actually runs can therefore differ from the national file.

Do Medicaid MUEs have adjudication indicators?

No. The Medicaid MUE tables list a value and a rationale for each code but carry no MUE adjudication indicator column, unlike the Medicare tables. Some rationale labels are Medicaid's own, such as Clinical: Medicaid Data and, in the outpatient hospital table, Inpatient Procedure.

Can the NCCI checker test a Medicaid claim?

Yes. Choose Medicaid in the checker to read the Medicaid practitioner, outpatient hospital or DME table; the answer also says whether Medicare bundles the same pair. A date of service from 2024-01-01 to 2026-12-31 leaves out edits that took effect later and keeps edits CMS has since deleted. The MUE lookup has the same Medicaid setting.

Do Medicaid managed care plans use these edits?

The national files describe the edits CMS distributes to state Medicaid programs. Managed care organizations that contract with a state follow the state's contract and their own payment policies, which can add edits or differ from the state's fee-for-service edits, so check the plan's published policies as well.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.

Disclaimer

Operational reference compiled from the national Medicaid and Medicare NCCI files. CMS: the edits in these files are active for dates of service October 1, 2026 to December 31, 2026, and the files should NOT be used by state Medicaid programs as their edit file. State Medicaid programs and Medicaid managed care plans apply their own versions of these edits. CPT codes appear as bare numbers. Not legal, clinical or billing advice.

Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.