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Edits Take 2!


By Melody Mulaik

We discussed some crazy new 2020 edits in a previous column and, fortunately, the Centers for Medicare and Medicaid Services (CMS) made some course corrections with the second quarter edits effective April 1, 2020.[1]

The most anticipated update was the change made to the CCI edit that bundled the Modified Barium Swallow Study into the Speech Pathologist code 92611. The deletion of the edit was published on April 1, 2020, but the effective date for the deletion is January 1, 2020. This means that CPT® code 92611 Swallowing Function with the Speech Pathologist and CPT® code 74230 Modified Barium Swallow can now be reported together and providers can expect their claims to be processed.

The other big area of concern was in nuclear medicine. On January 1, 2020, CMS implemented new Procedure-to-Procedure (PTP) CCI edits that bundled certain radiopharmaceuticals with Nuclear Medicine CPT® codes with the rationale listed as “Misuse of column two code with column one code.” Later in January, after reviewing this issue more closely, CMS made the decision to revise these PTP edits. These are the changes that were made for April 1, 2020, and made retroactive to January 1, 2020.

Although the specific radiopharmaceutical code edits vary slightly from one code to the next, some of the edits that were in place for 2020 have now been removed. It is important to note that not all of the edits for the radiopharmaceuticals have been removed.

Bone and Joint Nuclear Medicine Studies (CPT® Codes 78300 thru 78315): As an example, the radiopharmaceutical edits for Tc-99m medronate (A9503), TC-99m oxidronate (A9561), and Indium 111 labeled autologous platelets (A9571), have been removed for 78300 bone and/or joint imaging, limited area.

Myocardial PET and PET-CT Nuclear Medicine Studies (CPT® Codes: 78429 thru 78434): An example of the radiopharmaceutical edits removed for the myocardial PET and PET-CT is as follows: Tc-99m medronate (A9503), Nitrogen N-13 ammonia (A9526), Tc-99m microaggregated albumin (A9540), F-18 FDG (A9552), Rubidium Rb-82 (A9555), and Xenon Xe-133 gas (A9558) no longer have edits with 78432 Myocardial PET perfusion and metabolic evaluation dual radiotracer.

Tumor Localization, Inflammatory Process or Distribution of Radiopharmaceutical Agent Nuclear Medicine Studies including planar, SPECT and SPECT-CT (CPT® Codes: 78800 thru 78832): This series of codes has the most CCI edit deletions. This code series had between 18 and 40 radiopharmaceutical edits deleted per code so the information should be reviewed in detail.

When CMS determined they were going to revise the edits, they advised providers that they had a few options: (1) Providers could choose to delay submission of claims for deleted edits until after the implementation of the replacement edit file (4/1/2020) with retroactive date of January 1, 2020. (2) Providers could choose to appeal claims denied due to the PTP edits to the appropriate MAC including supporting documentation, or (3) Providers could resubmit claims denied due to these procedure to procedure edits after the implementation of the replacement edit file (4/1/2020) with January 1, 2020 retroactive date, as permitted by their local Medicare Administrative Contractor (MAC).

If you chose Option 1, you may now submit those claims and expect them to be processed for payment. If you have denied claims, you may now resubmit those claims with dates of service back to January 1, 2020 and expect them to be processed.

Melody W. Mulaik, MSHS, CRA, RCC, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle and Coding Strategies Inc.

1. https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes

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