2017-02-08 20:28:16 UTC

CMS is Mistakenly Denying Specific Moderate Sedation Codes

Feb. 8, 2017

The correction for the error with esophagogastric fundoplasty and unlisted procedure, colon, codes will take effect on April 1.

AGA has received notice from the Medicare National Correct Coding Initiative (NCCI) that errors were made in the practitioner procedure to procedure (PTP) edits version 23.0, which are causing denial of moderate sedation CPT codes 99151-99153 when reported with codes 43210 (esophagogastric fundoplasty) and 45399 (unlisted procedure, colon). 

As of Jan. 1, 2017, when a practitioner performs moderate sedation in addition to the underlying procedure that supports it, the practitioner must report the appropriate moderate sedation code(s) (99151-99153 and/or G0500) in addition to the procedure. However, codes 99151-99153 were incorrectly included in the bundles of 33 procedure codes, including 43210 and 45399, without allowing for bypass with an appropriate NCCI modifier. This means when they are billed with the 43210 and 45399 procedures, they will be denied.

According to NCCI staff, the correction for this error will take effect on April 1, 2017. At this time, the implementation of a workaround has not been determined. Because of this, practitioners may continue to see the denial of these codes until April 1. Practitioners are advised to consider delaying submission of claims for moderate sedation CPT codes 99151-99153 when performed with 43210 or 45399 until the new versions of NCCI PTP edits are implemented on April 1, 2017.  

Alternatively, if you do submit a claim including 43210 and/or 45399 with CPT codes 99151-99153 for the same date of service and the CPT code in the range 99151-99153 is denied, the denial may be appealed on or after April 1, 2017.

Watch an AGA webinar to learn more about moderate sedation CPT and G codes.

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