Are the CPT codes on the claim subject to a payer edit program?
Payers, including Medicare, often have edit systems for certain code pairs that are billed on the same day of service by the same provider. Some of these code combinations are understandable if you try to look at the issue from a payer perspective, but some make no sense. For example, under Medicare’s CCI edit system, Manual Therapy, 97140, is edited as a mutually exclusive edit with Functional Activities, 97530. This edited code pair does, however, provide for the use of a modifier. This modifier, like any other, must be supported by appropriate documentation. Most edits, referred to as component edits, are a payer’s method of trying to make sure that certain billed services are not actually a component of another billed service. Let’s look at a common edit and how this might be addressed in your documentation. Under Medicare, reevaluation, 97002, is edited with almost every CPT code in the 97000 series. If a provider is performing a reevaluation, 97002, as well as other interventions
