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CMS Revises Edit, Restores Modifier Use to a Code Pair; Influence of Allina Is Seen

In a sign that more coding and coverage changes may go through notice-and-comment rulemaking, the National Correct Coding Initiative (NCCI) contractor has revised an edit that prevented same-day billing for CPT codes 92611 (motion fluoroscopic evaluation of swallowing function by cine or video recording) and 74230 (radiologic examination, swallowing function, with cineradiography/videoradiography). Starting in April, providers will be able to bill for both services when they’re provided to the same patient on the same day with a modifier.

The edit took effect Jan. 1 when CMS announced updates to the NCCI procedure-to-procedure edit files, said Andrew Leibfried, director of regulatory and billing compliance for R1 RCM in Chicago.

“This new code pair that was added Jan. 1, 2020, was not eligible for a modifier, so you couldn’t even bypass the edit. They left providers with no option,” he said. “They were getting reimbursed for 74320 Dec. 31, and as of Jan. 1, they effectively changed reimbursement for this service.” But CMS has reversed course, retroactive to Jan. 1.

Leibfried believes that CMS overstepped with the NCCI edit, because it’s a significant payment change that was made without notice and comment rulemaking. He said that shouldn’t fly anymore in the wake of the 2019 Supreme Court decision in Azar v. Allina Health Services, et al.,[1] which requires CMS to use rulemaking, with its notice-and-comment period, for “substantive” changes to policies that affect payment and scope of benefits.

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