ACR Successfully Appeals NCCI PTP Edits

The Centers for Medicare and Medicaid Services (CMS) is expected to change the Correct Coding Modifier Indicator (CCMI) from 0 to 1 for vertebroplasty, kyphoplasty and sacroplasty with transforaminal and interlaminar injections. The action is the result of an appeal by the American College of Radiology® (ACR®) related to National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) Practitioner (PRA) edits.

NCCI PTP edits are in place to prevent payment for specific code combinations and to control improper coding that leads to inappropriate payment in Medicare Part B claims. A CCMI indicator of 0 disallows the use of a PTP-associated modifier to bypass the code pair edit under any circumstance. Conversely, a CCMI indicator of "1” does allow the use of a PTP-associated modifier to bypass the edit for separate and distinct studies, and medical necessity should be supported by documentation.

ACR argued there is no overlap of work, and the procedures are separate and distinct between vertebroplasty, kyphoplasty and sacroplasty from the transforaminal and interlaminar injections.

CMS expects to implement this change in the NCCI quarterly updates scheduled for Oct. 1, edit files.

Questions and comments may be directed to Maria Tran, ACR Director of Economics and Health Policy.