Claims temporarily denying incorrectly following CMS update

On September 14, CMS withdrew its National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits for the following code pairs (explanation below):

  • Column One: 80305, 80306, 80307 (presumptive drug tests)
  • Column Two: G0480, G0481, G0482, G0483, G0659 (definitive drug tests)

CMS turned on these edits on July 1, and we updated our systems to comply, applying the edits to facility and professional claims across all lines of business.

To align with this latest update, we’re now in the process of creating a workaround to allow claims to pay appropriately.

What are NCCI PTP edits?

NCCI PTP edits prevent inappropriate payment of services that shouldn’t be reported together.

Each edit has CPT/HCPCS codes in Column One and Column Two. If a provider reports the two codes of an edit pair for the same member on the same date of service (DOS), 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.

What’s the solution timeline & provider impact?

We anticipate having a solution in place in early October. Once that happens, we’ll automatically reprocess impacted claims back to July 1.

There’s no need for providers to resubmit.

In the meantime, providers will continue to see claim denials for the Column Two codes when billed with Column One codes for the same member on the same DOS.