On July 1, 2023, the Centers for Medicare and Medicaid Services (“CMS”) implemented a new National Correct Coding Initiative (“NCCI”) Procedure-to-Procedure (“PTP”) edit for codes 80305, 80306, and 80307 for presumptive drug test(s), and codes G0480-G0483, and G0659 for definitive drug test(s).
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 services.
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What does this mean for laboratories?
- Effective July 1, when laboratories submit claims for both the presumptive drug test and the definitive drug test, the definitive drug test will be denied.
- Currently, these edits cannot be bypassed using an NCCI modifier; however, CMS will change these edits to allow for the use of a modifier to bypass the edits in those circumstances when billing these codes together is allowable. These circumstances are generally defined by the Medicare Administrative Contractors (MACs) in Local Coverage Determinations.
- This change will be retroactive to July 1, 2023.
- Medicare will not implement this change, however, until Oct. 1, 2023, (with the next quarterly NCCI update).
What are labs doing in the meantime?
Based on our discussions with laboratories around the country, laboratories are handling the interim period between July 1, 2023, and Oct. 1, 2023, in the following ways:
- Laboratories are billing the MACs for these tests together and including the appropriate modifier on the claim. When the NCCI is updated next quarter, the MACs will adjust claims with dates of service between July 1, 2023, and Oct. 1, 2023, to allow payment on the definitive test when an NCCI modifier was used.
- Laboratories are using the MAC appeals process if they do not wish to wait for the automatic adjustment to occur. Appeals will need to be submitted after the initial denial and include supporting documentation.
- Laboratories are waiting to submit their claims (with the appropriate modifier as applicable) until CMS implements the modifier change on Oct. 1, 2023.
What is a modifier, and when should a modifier 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 specificity.
When utilizing a modifier, laboratories must ensure that documentation in the medical record satisfies the criteria required when using the modifier to override the NCCI edit.
What about other payors?
Most other payors typically follow the same edit rules within their systems as CMS. Therefore, we expect Medicaid and commercial payors to follow this new edit, including adoption of the use of applicable modifiers effective Oct. 1, 2023. However, at this time it is unknown what other payors will do, including whether any change will be given retroactive effect.
We will continue to monitor the situation and provide updates as available.
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Please Note: Information contained in this article is for general information purposes only and is not intended to provide billing or legal advice. Laboratories are encouraged to seek legal counsel or other guidance that is specific to their unique situation.