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Article Body
On January 1, 2013, new Procedure-to-Procedure (PTP) edits were implemented in the Medicare and Medicaid NCCI that paired the immunization administration codes (CPT codes 90460 – 90474) as column one codes with preventive medicine Evaluation & Management (E&M) service codes (CPT codes 99381 – 99397) as column two codes. All of the edits have a Correct Coding Modifier Indicator (CCMI) of “1”, which permits the edit to be bypassed, if a PTP-associated modifier is correctly appended to one of the CPT codes.
The edits are based on the instruction in the section on “Immunization Administration for Vaccines/Toxoids” in the 2013 CPT Manual, which states:
If a significant separately identifiable Evaluation and Management service (e.g., new or established patient office or other outpatient services [99201 – 99215], office or other outpatient consultations [99241 – 99245], emergency department services [99281 – 99285], preventive medicine services [99381 – 99429]) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes.
It has been long-standing CMS and NCCI policy that, when this type of instruction, which allows separate reporting of a significant, separately identifiable E&M service, is present, edits are established with a CCMI of “1”. This permits payment of both codes, if a significant, separately identifiable E&M service is provided on the same day and a PTP-associated modifier (i.e., modifier 25) is appended to the E&M code. The edit prevents inappropriate payment of a preventive medicine E&M service, if the beneficiary just returns to the physician's office for the immunization on a day other than the day of a comprehensive preventive medicine E&M service. Many similar edits have been present in the NCCI program for a number of years.
As a result of comments received from the American Academy of Pediatrics and some state Medicaid agencies, CMS has decided to permit state Medicaid agencies to deactivate these edits in their Medicaid Management Information Systems through the end of 2013, if they choose to do so, retroactive to January 1, 2013. States do not have to file a formal deactivation request through their CMS Regional Office to do so. Table 1 identifies the edits in question.
State Medicaid agencies that choose to retain the edits should educate providers to report E&M codes with immunization administration codes, if the E&M service is significant and separately identifiable. States should notify providers that the proper use of modifier 25 with an E&M service code will bypass the PTP edits.