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