Following a post-adjudication audit, McLaren Health Plan identified claims that were inappropriately reimbursed. State Medicaid programs are expected to use Medicaid National Correct Coding Initiatives (NCCI) policies and edits to process claims. NCCI edits for Procedure to Procedure (PTP) define pairs of HCPCS/CPT codes that should not be reported together for a variety of reasons. Per CMS Policy, PTP edits prevent improper payments when incorrect code combinations are reported. Dates of services impacted are from 1/1/2023 to current. This will be an ongoing post-payment audit with future recoupment projects.

Below is the list of announcements and claim topics these audits are referring to. 

• Bilateral Modifier
• Global Surgery
• Medically Unlikely Edits
• Procedure to Procedure (PTP)
• Status B Bundled Payment