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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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PTP Basics

PTP Edits-Practitioners: These PTP code pair edits are applied to claims submitted by physicians, nonphysician practitioners, and Ambulatory Surgery Center (ASCs).

PTP Edits-Hospital: PTP edits are applied to Types of Bills (TOBs) subject to the Outpatient Code Editor (OCE) for OPPS. These edits are applied to outpatient hospital services and other facility services including, but not limited to, therapy providers (Part B Skilled Nursing Facilities (SNFs)), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech-language pathology providers (OPTs), and certain claims for home health agencies (HHAs) billing under TOBs 22X, 23X, 75X, 74X, 34X.

What are the Column 1/Column 2 PTP Code Pair Tables?

Although the Column 2 code is often a component of a more comprehensive Column 1 code, this relationship is not true for many edits. In the latter type of edit, the PTP code pair edit simply represents two codes that should not be reported together, unless an appropriate modifier is used.

Many procedure codes should not be reported together because they are mutually exclusive of each other. Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same beneficiary encounter.

When is a code the reimbursable code of a PTP code pair?

The Column 1/Column 2 tables are comprised of PTP code pairs. If a provider submits the two codes of an edit pair for payment for the same beneficiary on the same date of service, the Column 1 code is eligible for payment and the Column 2 code is denied. However, if both codes are clinically appropriate and an appropriate NCCI-associated modifier is used, the codes in both columns are eligible for payment. Supporting documentation must be in the beneficiary’s medical record.

 Column 1  Column 2  Column 3  Column 4  Column 5  Column 6  Column 7
 Code 1  Code 2 In existence prior to 1996 Effective Date Deletion Date

Modifier

0=not allowed

1=allowed

9=not applicable
PTP Edit Rationale
 97530  97532   20020401 20171231  1 More extensive procedure
 97530  97533   20020401    1 More extensive procedure
 97530  97535   20201001    1 More extensive procedure
 97530  97535   19990701 20191231  1 More extensive procedure
 97530  97537   19990101    1 More extensive procedure
 97530  97542   19990101    1 More extensive procedure
 97530  97750   19990701 20191231  1 More extensive procedure
 97530  97750   20201001    1 More extensive procedure
 97530  97755   20040401 20060930  1 More extensive procedure

Column 1 indicates the payable code.

Column 2 contains the code that is not payable with this particular Column 1 code, unless a modifier is permitted and submitted.

Column 3 indicates if the edit was in existence prior to 1996.

Column 4 indicates the effective date of the edit (year, month, date).

Column 5 indicates the deletion date of the edit (year, month, date).

Column 6 indicates if use of a modifier is permitted. This number is the modifier indicator for the edit.

Column 7 provides the underlying basis for each PTP edit.

Reference

How to Use the Medicare National Correct Coding Initiative (NCCI Tools)

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