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Surprising Changes to CMS NCCI Procedure to Procedure (PTP) Edits with April 2020 Update

Surprising Changes to CMS NCCI Procedure to Procedure (PTP) Edits with April 2020 Update

The Centers for Medicare and Medicaid Services (CMS) posted their regular quarterly updates to the hospital and practitioner NCCI PTP edits earlier this month. Typically the April 1 updates are pretty benign, with few changes compared to what gets updated every year on January 1.  However, this year’s April updates are anything but uneventful. On April 8, 2020, CMS posted an announcement on their website indicating they updated PTP and Medically Unlikely Edits in response to the COVID-19 Public Health Emergency and the expansion of telehealth services retroactive to January 1, 2020.

This update includes over 100 changes to PTP edits applicable to PT, OT and SLP. Most of these changes are deletions to long-standing code pairings, such as the requirement for modifier 59 when 97530 and 97116 and when 97150 and 97110 are billed together for the same patient on the same day. APTA cautioned in their announcement about the edit changes that payer systems may not yet be updated and that commercial payers who follow these edits may or may not realize these changes have happened. It is also unknown at this time if these changes are “permanent” or if they will be in place only for the duration of the public health emergency.

 Access the list of the changes outlined in the April update.

Access the updated PTP edit tables.

Holly Hester

Holly Hester is Casamba’s Senior Vice President of Compliance & Education, as well as the Compliance Officer. She provides regulatory guidance and interpretation, clinical programming and content development, education and training steerage, and compliance support for the company. As a physical therapist for more than 20 years, Holly has multi-venue clinical and management experience, giving her a unique perspective on the integration of compliance and training with therapy service delivery and clinical practice.
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