Internal Medicine Coding Alert

Published on Thu Jan 17, 2013 PDF

Question: One of my third-party payers is denying L4360 because they are asking for "the appropriate modifier." Should we use a modifier when billing this code?

Connecticut Subscriber

Answer: Some payers have an LCD (local coverage determination) for L4360 (Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment) that provide guidance for filing claims. Noridian in Washington, for example, lists several modifiers that are relevant to L4360, such as EY (No physician or other licensed health care provider order for this item or service), KX (Requirements specified in the medical policy have been met), GA (Waiver of liability statement issued as required by payer policy, individual case), and GZ (Item or service expected to be denied as not reasonable and necessary).

Another option: The payer might want something as simple as either modifier LT (Left side) or RT (Right side). Start by checking with the payer in question to see if such guidelines exist.