Modifier Mix-up Causes Claims Denials

If your practice can’t seem to successfully bill for the professional component lately, there could be a logical explanation. It could be something as simple as an incorrect modifier.

According to First Coast Service Options Inc. (FCSO), an excessive number of claims from providers are being denied because they request payment for the professional component using the wrong modifier with the CPT® or HCPCS Level II code.

Prevent Delays and/or Denial

When billing for the professional component of a procedure, hospital outpatient departments, ambulatory surgical centers (ASCs), and other practitioners should properly identify the service by adding modifier 26 Professional component to the appropriate CPT® or HCPCS Level II code — not the new modifier effective July 1,  PC Wrong surgery on patient.

Medicare automatically denies all lines related to an erroneous surgery with dates of service on or after Jan. 15, including claims for related hospitalizations.

Claims Appeal


FCSO advises providers appeal claims billed in error with modifier PC and subsequently denied for wrong surgery. Correcting and resubmitting these claims won’t work. Only an appeal will remove the edit logic that was installed for the beneficiary and date of service of the wrong surgery based on the initial claim.

One Response to “Modifier Mix-up Causes Claims Denials”

  1. Doretha Pugh says:

    Thank you for the information on this site, I will definitely be on this site, I am preparing to take the Examination on 11/24/009 so that I will be certified For Medical Billing and Coding. I will share the cite with my classmate. This is infomation we need as Medical Billers and Coders.

    Thank You

    Doretha Pugh

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