OPPS and Non-OPPS Providers: Implemented Billing Requirements

National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits are used by claims processing systems to adjudicate provider claims for physician services, outpatient hospital services, and outpatient therapy services. These edits apply to Critical Access Hospitals (CAH), Outpatient Rehabilitation Facilities (ORF), Skilled Nursing Facilities (SNF), Community Mental Health Centers (CMHC) and End Stage Renal Disease (ESRD) facilities. They are not applied to facility claims for inpatient services. Noridian's website can help you locate the NCCI tables, provide tools on how to look up PTP code pair edits and determine when to use an appropriate modifier.

The recent implementation of the July and October 2018 Integrated Outpatient Code Editor (I/OCE) logic was updated to review OPPS and non-OPPS claims submitted for the same beneficiary, provided by the same provider and on the same date of service. It will assign specific edit numbers and dispositions, where in the past; this type of detail was not provided. These facility claims billed after the effective date are now subject to these updated rejections.

Bill Type/Provider
Edits Applied
12X, 14X without CC 41 W7020, W7040
13X W7020, W7040
85X CAH W7020, W7040


Bill Types/Provider
Edits Applied
22X, 23X SNF W7020, W7040
72X ESRD W7020, W7040
74X ORF W7020, W7040
76X CMHC W7020, W7040


Provider Action Required – OPPS and non-OPPS

Providers can verify the NCCI PTP edits applied to the claim or line item and make the necessary corrections, if applicable. Reason code W7020 means a HCPC or CPT code pair billed is not allowed even with an appropriate modifier when it is billed on the same date of service. Reason code W7040 means the HCPC pair billed may be allowed to add a modifier when the service is distinct and documented as reasonable and necessary.

CAH example of PTP editing

Revenue Code HCPC Service Date Total Unit Covered Unit Covered Charges Non-covered Charges Line Item Reason Code
0510 96372 1025 1 1 21.00    
0510 99214 1025 1     33.00 W7040


PTP Hospital Edits – Search for 96372 paired with 99214

Column 1
Principal Procedure
Column 2 Effective Date Deletion Date Modifier PTP Edit Rationale
96372 99214 20090101 N/A 1 =allowed Misuse of column two code with column one


Note: All health care professionals and health care organizations are responsible to follow the adjustment or claims correction process for proper billing. This may require providers to delete the line in error and resubmitting (rekey) the line with modifier, if applicable.

View these resources for more information.

            Last Updated Fri, 06 Mar 2020 11:24:03 +0000