Navigating the New NCCI PTP Edits: Implications for Drug Testing

CMS’s Updated Billing Procedures and Their Impact on Laboratories

As of July 1, 2023, the Centers for Medicare and Medicaid Services (CMS) implemented an updated National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edit. The revised codes include 80305, 80306, and 80307 for presumptive drug tests, and codes G0480-G0483, and G0659 for definitive drug tests1.

Understanding NCCI Edits

What is an NCCI edit? NCCI Procedure-to-Procedure (PTP) code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B-covered services2.

What does this mean for laboratories? From July 1, labs submitting claims for both the presumptive and definitive drug tests will have the definitive drug test denied. However, CMS will retroactively change these edits from July 1, 2023, to allow a modifier to bypass the edits when billing these codes together is permissible3.

Laboratory Options: During the transitional period spanning July 1 to Oct. 1, 2023, laboratories are:

  1. Billing the MACs for these tests concurrently, appending the relevant modifier to the claim. Post the next NCCI update, MACs will recalibrate claims dated between July 1 to Oct. 1, 2023, to facilitate payment on the definitive test where an NCCI modifier has been applied.
  2. Opting for the MAC appeal method if they don’t prefer waiting for automatic adjustments. Following the initial refusal, appeals must be lodged with supportive documents.
  3. Choosing to delay their claims submissions (incorporating the suitable modifier) until CMS authorizes the modifier alteration on Oct. 1, 2023.

What is a modifier, and when should it be used? Modifiers indicate that a service or procedure performed has been altered by some specific circumstance but not changed in its definition or code. They are used in billing, on the claim form, to add information or change the description of a service to improve accuracy or specificity5.

How will other payers respond? Most payers typically follow the same edit rules within their systems as CMS. Therefore, we expect Medicaid and commercial payers to follow this new edit, including adopting applicable modifiers effective Oct. 1, 20236.

Alternative Biomedical Solutions (ABS) is committed to providing customer-focused solutions in these changing times. We remain dedicated to assisting labs in navigating these changes and ensuring the provision of high-quality services to patients.

Source: CMS NCCI Edits.

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