CMS releases 2^nd Quarter PTP and MUE Version Updates

The Centers for Medicare & Medicaid Services (CMS) recently released the April 2018 code pair tables for providers to review before filing claims. CMS developed the national correct coding initiative (NCCI) to promote correct coding methodologies and to control improper coding that leads to inappropriate payment on Part B Medicare claims. NCCI procedure-to-procedure (PTP) code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together. These edits also include Medically Unlikely Edits (MUE) updates and are updated and published by CMS each quarter.

To simplify, PTP edit pairs represent CPT/HCPCS codes that cannot be reported together for the same patient on the same date of service, while an MUE represents the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

NCCI PTP code pair edits are presented in the Column 1/Column 2 Correct Coding Edits table available via the CMS website. If a provider submits two code pair edits for payment for the same beneficiary on the same date of service, the Column 1 code is eligible for payment and the Column 2 code is denied. However, if both codes are clinically appropriate and an appropriate NCCI-associated modifier is used, the codes in both columns are eligible for payment. Supporting documentation must be in the beneficiary’s medical record.

Click the link below to download the code pair tables.

Quarterly Additions, Deletions, and Modifier Indicator Changes to NCCI edits for Physicians/Practitioners (column 1 / column 2 edits and mutually exclusive code edits) Effective April 1, 2018  – External Link Policy-Opens in a new window

In short, these are things you can implement today:

• Check CCI to know if a PTP edit exists before appending a modifier
• When a modifier is required, audit the documentation to verify it is supported
• When in doubt, refer to your complete code descriptions

A final point that must be mentioned, not all carriers are created equal. This information is based on NCCI edits developed by CMS. Some commercial and third-party payors have their own edits in place, so it is important to know your payors guidelines before submitting claims to ensure you are maximizing reimbursement.

Coding services are the life-blood of your practice. That is how the services you provide are transformed into billable revenue. It takes a knowledgeable and experienced coding staff to maximize your billed charges while maintaining strict compliance with CMS and CCI guidelines. Trust the coding experts at Merem Healthcare Solutions.  At MEREM, we don’t just provide services, we deliver solutions.