Wiki 81220 & 81420

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Hey everyone,

I am getting denials relating to code 81220 being inclusive to procedure 81420. Does anyone know why the carrier would deny this way?
 
CMS NCCI policy bundles 81220 into 81420, which is why it would be denied.

I believe the general source of the CCI policy is this CMS policy below, which prohibits duplicate, confirmatory testing for the same analyte on the same DOS. In my opinion though, I think CMS was overly cautious when creating this CCI/PTP edit. CPT 81420 tests chromosomes 13, 18, 21, while CPT 81220 tests for CFTR gene, which is on chromosome 7. Since these CPT codes test different chromosomes, I think modifier 59 would generally be supported for CPT 81220 to bypass the CCI edit and pay, since you're testing different chromosomes per CPT definition.


All genomic sequencing procedures and molecular multianalyte assays (e.g., CPT codes 81410-81471), many multianalyte assays with algorithmic analyses (e.g., CPT codes 81490-81599, 0004M-XXXXM), and many Proprietary Laboratory Analyses (PLA) (e.g., CPT codes 0001U-XXXXU) are DNA or RNA analytic methods that simultaneously assay multiple Revision Date (Medicare): 1/1/2022 X-8 genes or genetic regions. A provider/supplier shall not additionally separately report testing for the same gene or genetic region by a different methodology (e.g., CPT codes 81105-81408, 81479, 88364-88377). CMS payment policy does not allow separate payment for multiple methods to test for the same analyte.
 
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