NCCI Edits and Version 27.0

December 11, 2020
Rick Gawenda

The Centers for Medicare and Medicaid Services (CMS) has released the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits Version 27.0 that will be effective with dates of service January 1, 2021 through March 31, 2021. CMS has deleted several of the NCCI PTP edits that they had reinstated for dates of service October 1, 2020 through December 31, 2020 that had a negative impact on outpatient physical, occupational and speech therapy services.

NCCI PTP edits that CMS deleted that have an impact on outpatient therapy services include:

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In addition, CMS deleted the following NCCI PTP edits that impacted therapy services when provided in the emergency department:

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To access Gawenda Seminars & Consulting NCCI Edit modifier 59 reference sheet, click HERE. I hope you found this article helpful. Thank you for being a Gold Member!

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    1. Please look at the current edition and look to see the deletion dates of some of the PTP edits. Many of them go retro back to January 1, 2020.

  1. If I’m interpreting the Version 27 referent sheet correctly, we no longer need the 59 modifier on 97530 when billed with 97140? and no longer need the 59 modifier on 97140 when billed with an eval code? From your experience, are these Edits applicable to the medicaid insurances, and do commercial insurances follow – sooner or later?

    1. Whether or not commercial insurances will follow suit is payer specific. History tells us they do not.

        1. Typically, yes, but you need to verify as many Medicaid programs are managed Medicaid programs by some of the commercial insurance carriers.

  2. deleted edits meaning you can no longer bill those together on the same day with a modifier or meaning you no longer need the modifier for 97530 with 97113? I billed both codes together with modifier as usual and was only paid the 97530 not the 97113 – one paid unit vs total of 4. ??

  3. I listened to your post re: billing 97750 for Tinetti, Berg etc. It looks like 97750 is now allowed on same day billing as an Eval with a 59 modifier…just making sure i’m seeing correct on your CCI cheat sheet for Jan 1 2021?

  4. Does Medicare still deny 97530 when billed with an Eval code? If so, is this something you see changing in the near future?

  5. We have a question…we are located in Kansas & we are having issues with UHC Community Plan, and some other payers not want to process 97530 when billed with 97140. Even when we do a reconsideration & provide supporting documentation (i.e. information on NCCI PTP Edits from CMS, Gawenda and APTA. Any advise?

    Thank you,

    1. Have your patients and their employers contact the insurance carrier as well as have them file a complaint with your States Insurance Commissioner.

  6. I just looked at the current PTP pairs and 97140 and 97530 are requiring a modifier–is this different than what is published here and in the Medicare tab–NCCI edits?