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New NCCI Edits

Important Notice: New NCCI Edits Effective April 1, 2014, for Immunization Administration & Preventive Visit Codes, with Dates of Service on or after January 1, 2013

In mid-February 2014, CMS notified states that effective April 1, 2014, National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits that pair immunization administration codes (CPT codes 90460 – 90474) as column one codes, with the preventive medicine Evaluation & Management (E&M) service codes (CPT codes 99381 – 99397) as column two codes, must be implemented for dates of service on or after January 1, 2013.  As you may know, column 2 codes are not reimbursed separately when billed on the same date of service by the same provider unless an appropriate modifier is appended to clarify the service(s) delivered.  

Originally, these immunization administration/preventive visit PTP edits were included in the NCCI edits effective January 1, 2013.  However, due to concerns expressed by a number of sources, required implementation was delayed by CMS and the states were given the option to implement the edits for 2013 dates of service, if desired.  At that time, West Virginia Medicaid opted not to implement the edits. 

Effective April 1, 2014, the implementation of these PTP edits means that if a Medicaid beneficiary receives one or more immunizations and a “significant, separately identifiable” preventive-medicine evaluation-and-management (E&M) service from the same provider on the same date of service, the provider’s claim(s) should include both the immunization administration code (CPT codes 90460 – 90474) and the comprehensive preventive-medicine E&M code (CPT codes 99381 – 99397) with the appropriate modifier appended.  Claims with the applicable codes and dates of service that are processed by Molina, prior to April 1, 2014, will not be reprocessed to apply the edits. 

WV Medicaid apologizes in advance for any inconvenience this late notice may cause. 

View this information as a PDF file by clicking here.

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