CMS releases quarterly update to PTP edits and MUEs

CMS finalized changes to NCCI Medically Unlikely Edits (MUE) and procedure-to-procedure (PTP) edits in its quarterly update to NCCI edit files, effective April 1.

CMS updates its NCCI edit tables on a quarterly basis and uploads them to its website and into Medicare claims payment processing systems. CMS recently posted updated NCCI edit tables for practitioner services, outpatient hospital services, and Durable Medical Equipment supplier services to its website, which summarize quarterly additions, deletions, and revisions to PTPs and MUEs published for calendar year 2019.

Each MUE table includes updated HCPCS or CPT codes and their associated MUE values or the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

For example, in its update to MUEs for outpatient hospital services, CMS listed CPT code 20250 (biopsy, vertebral body, open; thoracic), which was listed previously as having an MUE value of 3, as now having a MUE value of 1. This means that a maximum of 1 unit of service should be applied to Medicare claims billed for this procedure when it’s rendered by one provider for one patient on a single day.

Each PTP table includes CPT and HCPCS code pairs that either should never be reported together by the same provider for the same patient on a single date of service or that may only be reported together in defined circumstances by use of an NCCI-associated modifier.

For example, in its update, CMS listed new guidance for reporting CPT codes 0001M (infectious disease, HCV, six biochemical assays utilizing serum, prognostic algorithm reported as scores for fibrosis and neuroinflammatory activity in liver) and 80076 (hepatic function panel). According to the updated PTP edit table, these two codes should never be reported together by the same provider for one beneficiary on a single date of service.

Notably, CMS also released Transmittal 4266 on March 29, announcing updates to NCCI PTP edits, effective for claims submitted on or after July 1. However, the agency doesn’t anticipate that these updates will be posted to their website until late May.