VOL. 2, ISSUE 4 | SEPTEMBER 2023
New CMS Billing Edits for Preemptive and Definitive Drug Tests to be Rescinded October 1st
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 affecting codes for presumptive (i.e., CPT® codes 80305, 80306, and 80307 ) and definitive (i.e., G0480-G0483 , and G0659 ) drug tests. NCCI PTP code pair edits are automated prepayment edits that prevent improper payment when specific codes are submitted together for Part B services. This new edit was adopted to prevent the reimbursement of a presumptive and a definitive drug test for the same patient on the same date of service (DOS), which CMS deemed “mutually exclusive.” The edit results in claims for definitive drug testing being automatically denied when billed on the same claim with presumptive tests. CMS published the quarterly update to the NCCI PTP file on September 1, 2023, with the new file effective October 1, 2023. Subsequently, on Wednesday, September 6th, 2023 the American Clinical Laboratory Association (ACLA), received word from the Deputy Administrator and Director of the Center for Program Integrity at CMS, that the agency is withdrawing the NCCI PTP drug testing edit . According to the communication received by ACLA, the change will be operational on October 1, 2023, and fully retroactive to July 1. The XiFin team also received the following information from the National Correct Coding Initiative (NCCI) program. CMS has since posted the withdrawal on the CMS website . It is important to keep in mind that payors are using technology to identify indicators of possible overutilization and as an industry we may see an uptick in third-party audits to root out any overutilization. If you have questions related to this issue, please contact your Customer Success Manager (CSM) (or Customer Account Manager (CAM) for outsourced billing services customers). “CMS considered the concerns raised by the lab industry and decided to withdraw the NCCI PTP edits between Column One codes 80305, 80306, and 80307 for presumptive test(s), and Column Two codes G0480 – G0483, and G0659 for definitive test(s) while CMS continues to study the issue.” “CMS will work to operationalize this change in a replacement file for the 4th quarter of 2023 and will apply it retroactively to July 1, 2023. As a result, any claim that was affected by the procedure-to-procedure edits, including those that did not apply an NCCI modifier, will be processed and paid as appropriate under existing payment and coverage policies. CMS will post the replacement file on the NCCI PTP webpage as soon as technically possible.”
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