Description
Claims for CPT/HCPCS codes that are billed with a TC and/or PC modifier in addition to the global procedure by the same provider, will be denied.
Affected Code(s)
All eligible codes except the following: 76519, 92136, 51725, 51726, 51727, 51728, 51729, 51736, 51741, 51784, 51785, 51792, 88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88319, 88329, 88331, 88332, 88333
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Claims Processing Manual, Chapter 1 (General Billing Requirements), §120 (Detection of Duplicate Claims)
8. Medicare Claims Processing Manual, Chapter 12 Physician/Non-physician Practitioners, §20.2 Relative Value Units (RVUs)
9. Medicare Claims Processing Manual, Chapter 13 (Radiology Services and Other Diagnostic Procedures), §20.1 (Professional Component [PC]), 20.2 (Technical Component [TC]), and 20.2.3 (Services Furnished in Leased Departments)
10. Medicare Claims Processing Manual, Chapter 16 (Laboratory Services), §80.2.1 (Technical Component [TC] of Physician Pathology Services to Hospital Patients)
11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
12. Facility Outpatient Hospital Services and Practitioner Services MUE Tables, Link: https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medically-unlikely-edits
13. Medicare Fee-for-Service Payment/Physician Fee Schedule PFS Relative Value Files, Link: PFS Relative Value Files | CMS