How to Find BRCA or other Correct Coding Edits at CMS

In October 2017, I wrote a blog on the discovery that CMS has edits against paying for 81211 and 81213 on the same day - here.  This was surprisingly, because public data for 2015 and 2016 showed that CMS regularly paid for 81211 and 81213 on the same day - in fact, this code pair was about the most common genetic test there is.

In December 2017, I noted that CMS had changed the reason for this code edit, although the code edit itself remained identical.  Here. 

The reason for the edit became: "HCPCS/CPT procedure code definition."  This makes sense to me, because when you do 81211 81213 on the same day, the sequencing and dup del result is the same as 81162 (BRCA seq + dup del).   CMS priced 81162 by adding the prices of 81211 and 81213, plus a 10% discount.

There isn't any similar edit for Lynch sequencing and dup del analysis (81435+81436).  This is because there isn't any comprehensive code, and you report the results via the two codes.  Were there a comprehensive for 81435+81436, presumably for consistency CMS would price it at 90%x(81435+81436).  This is how it priced 81162 (81211+81213).

How Do You Find This Stuff?

Correct Coding Edits have existed since around 2000.  There are two types.  The first is "MUE" or medically unlikely edits.  These are based on the quantity of ONE code.  For example, per day you get one heart transplant, or one BRCA test, or one appendectomy.   It's medically unlikely or unbelievable to do otherwise.

The other type of edit is code-to-code edit.  These are codes where you can't bill both on the same day.  In some cases, these are fixed edits, in some cases they can be overcome by a modifier.   For example, you don't normally bill an office visit with a colonoscopy, but in some rare situation you might, so a modifier would be used.

The CMS home page for all this stuff is here:
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

You can get ZIP files for MUE edits, updated each quarter, and ZIP files for procedure to procedure or P2P edits, which are far more voluminous.

Currently, BRCA Procedure Edits and MUE edits are as shown below:

click to enlarge