Procedure-to-procedure (PTP) edit

Procedure-to-Procedure (PTP) edit is a term commonly used in healthcare revenue cycle management (RCM) to refer to a type of claim edit that is designed to identify and prevent improper billing practices. PTP edits are implemented by payers, such as insurance companies or government healthcare programs, to ensure that healthcare providers are submitting accurate and appropriate claims for reimbursement.

In simple terms, a PTP edit is a system that compares two or more procedure codes submitted on a claim to determine if they are compatible or appropriate when performed together. The purpose of this edit is to identify potential instances of unbundling or inappropriate billing, where separate procedures that should be billed together are instead billed separately to increase reimbursement.

To better understand the concept of PTP edit, it is essential to have a basic understanding of healthcare billing and coding. Healthcare providers use specific codes, known as Current Procedural Terminology (CPT) codes, to describe the services they provide to patients. Each CPT code corresponds to a specific medical procedure or service.

When submitting a claim for reimbursement, healthcare providers must accurately assign the appropriate CPT codes to reflect the services rendered. However, in some cases, providers may attempt to maximize reimbursement by unbundling procedures or billing for services that are not medically necessary.

PTP edits are put in place to prevent these improper billing practices. They compare the submitted CPT codes on a claim and determine if they are compatible or appropriate when performed together. If the edit identifies any discrepancies or potential issues, the claim may be denied or flagged for further review.

While PTP edits and the National Correct Coding Initiative (NCCI) share similarities in their purpose of preventing improper billing, they are distinct concepts within healthcare revenue cycle management.

The NCCI is a set of coding guidelines developed by the Centers for Medicare and Medicaid Services (CMS) to promote correct coding methodologies and prevent inappropriate payment of services. It includes both Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs).The main difference between PTP edits and NCCI is their scope. PTP edits specifically focus on identifying and preventing improper billing practices related to the compatibility of procedure codes. On the other hand, NCCI encompasses a broader range of edits, including PTP edits, MUEs, and other types of edits that address issues such as mutually exclusive procedures, unbundling, and inappropriate code combinations.

In summary, PTP edits are a subset of the NCCI and are specifically designed to identify and prevent improper billing practices related to the compatibility of procedure codes.

To illustrate the application of PTP edits, let's consider a few examples:

Example 1: Unbundling of Procedures

A healthcare provider submits a claim with CPT codes for an upper gastrointestinal (GI) endoscopy (CPT code 43239) and a biopsy of the stomach lining (CPT code 43659). However, the PTP edit system identifies that the biopsy is an integral part of the endoscopy procedure and should not be billed separately. The claim may be denied or adjusted to reflect the appropriate billing.

Example 2: Incompatible Procedures

A claim is submitted with CPT codes for a knee arthroscopy (CPT code 29881) and a shoulder arthroscopy (CPT code 29827). The PTP edit system recognizes that these procedures are not typically performed together and flags the claim for further review. The provider may need to provide additional documentation justifying the medical necessity of performing both procedures during the same encounter.

These examples demonstrate how PTP edits play a crucial role in identifying potential instances of improper billing, such as unbundling or incompatible procedure combinations. By implementing PTP edits, payers can ensure that healthcare providers are submitting accurate claims and receiving appropriate reimbursement for the services provided.In conclusion, Procedure-to-Procedure (PTP) edits are an essential component of healthcare revenue cycle management. They help prevent improper billing practices by comparing the compatibility of procedure codes submitted on a claim. PTP edits, along with other coding edits like those included in the NCCI, play a vital role in promoting accurate billing and ensuring the integrity of the healthcare reimbursement process.