Through coordinated outreach efforts, the American College of Radiology® and American Society for Radiation Oncology appealed National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits for 3-D radiotherapy plan. The outreach was in response to the Office of Inspector General’s report on Medicare payment policy for three-dimensional conformal radiation therapy planning service (3D-CRT) as previously reported in the June 29 Advocacy in Action e-newsletter, which resulted in Centers for Medicare and Medicaid Services (CMS) payment policy revisions to include PTP edits. For more than a year, Radiation Oncologists experienced claim denials across all seven Medicare Administrative Contractors when billing CPT codes 77280, 77285, 77290, 77336 with 77295.
The successful appeal led to CMS’ deletion of NCCI PTP edits for 3-D radiotherapy plan and therapeutic simulation CPT code pairs 77295/77280, 77295/77285 and 77295/77290.
CMS will retain the 3-D radiotherapy plan and medical physics consultation NCCI PTP edit for CPT code pair 77295/77336 with a correct coding modifier indicator (CCMI) of “1,” which will allow the reporting of this code combination.
Claims that were previously denied will be addressed by CMS and your Medicare Administrative Contractors (MACs). Providers will not have to resubmit claim information for payment. Allow time for MACs to reprocess claims and remit payment based on the latest NCCI update. Questions regarding specific claims should be addressed to your MAC.
The NCCI PTP updates are available in the Jan. 1, 2021 edit files for Medicare and Medicaid on the CMS website.