Wiki PTP Edits

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adunlap23

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Hello all!
I need help with PTP edits. One of the physicians I work for tried to bill 26145 with 26055. According to the NCCI PTP edits, 26055 is included in 26415. However, it was given a 1 on the chart, which I believe means they can be billed together under the right circumstances and with the correct modifier.
Can someone give me an example of when it would be appropriate to bill 26145 with 26055 and which modifier would be appended?
Thank you so much, in advance!
 
adunlap79@southhills.edu said:
Hello all!
I need help with PTP edits. One of the physicians I work for tried to bill 26145 with 26055. According to the NCCI PTP edits, 26055 is included in 26415. However, it was given a 1 on the chart, which I believe means they can be billed together under the right circumstances and with the correct modifier.
Can someone give me an example of when it would be appropriate to bill 26145 with 26055 and which modifier would be appended?
Thank you so much, in advance!
Click to expand...

An example would be if the procedures were on different hands. When you add a modifier to override an NCCI edit, you're stating that the procedures were unrelated. If they were on different hands, you could use the LT and RT modifiers to override the edit.

The CMS website has some information about what modifiers can be used for edits. Choose the one that is most applicable to the claim/the surgeries.

NCCI Modifiers​

A. What modifiers are allowed with the NCCI PTP edits?

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include:

Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
Global surgery modifiers: 24, 25, 57, 58, 78, 79
Other modifiers: 27, 59, 91, XE, XS, XP, XU

It is very important that NCCI PTP-associated modifiers only be used when appropriate. In general, these circumstances relate to separate patient encounters, separate anatomic sites, or separate specimens.
 
Thank you, Susan. I thought this was the case but the particular physician I am coding for is trying to us to bill 26055 with 26145 for work he performed on the same index finger. I wanted to be certain of the rules before I questioned him.
Your help is much appreciated!
 
adunlap79@southhills.edu said:
Thank you, Susan. I thought this was the case but the particular physician I am coding for is trying to us to bill 26055 with 26145 for work he performed on the same index finger. I wanted to be certain of the rules before I questioned him.
Your help is much appreciated!
Click to expand...
Something to keep in mind while speaking to your provider is that surgeons have a "Buffet" way of thinking. They know that there is a code for every procedure, and every procedure with a code can be billed in their mind. Since these procedures were performed on the same digit there is no way for both to be reported. Keep in mind that surgeon's generally have a specific mind-set due to the way that they are trained. I have seen countless times where one of my hand surgeons cuts the carpal tunnel ligament to look for a severed tendon, and they add 64721 to the list of procedures performed.
 
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