CMS Rescinds Billing Edits for Preemptive and Definitive Drug Tests

On Wednesday, September 6th, 2023 the American Clinical Laboratory Association (ACLA), received word from the Deputy Administrator and Director of the Center for Program Integrity at the Centers for Medicare and Medicaid Services (CMS), that the agency is withdrawing the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) drug testing edit, fully retroactive to July 1.

This overrides the NCCI PTP edit that went into effect July 1, 2023, affecting codes for presumptive (i.e., CPT® codes 80305, 80306, and 80307) and definitive (i.e., G0480-G0483, and G0659) drug tests. NCCI PTP code pair edits are automated prepayment edits that prevent improper payment when specific codes are submitted together for Part B services.

CMS has since posted the withdrawal on the CMS website

The XiFin team also received the following information from NCCI confirming the rescission:

“CMS considered the concerns raised by the lab industry and decided to withdraw the NCCI PTP edits between Column One codes 80305, 80306, and 80307 for presumptive test(s), and Column Two codes G0480 – G0483, and G0659 for definitive test(s) while CMS continues to study the issue.”

“CMS will work to operationalize this change in a replacement file for the 4th quarter of 2023 and will apply it retroactively to July 1, 2023. As a result, any claim that was affected by the procedure-to-procedure edits, including those that did not apply an NCCI modifier, will be processed and paid as appropriate under existing payment and coverage policies. CMS will post the replacement file on the NCCI PTP webpage as soon as technically possible.”

Source: https://www.cms.gov/ncci-medicare