Wiki 81220 & 81420

[Longaro]

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?

 

[mkarpin2]

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.

https://www.cms.gov/files/document/chapter10cptcodes80000-89999final11.pdf

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.