Wiki 87481 Billed with multiple units HELP!!!! Insurance will only pay 1 unit

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Sue2424

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We have been billing code 87481 with 4 units and the insurance companies are only paying for 1 unit. We have billed with and without modifier 91, w/mod 91 we got denial. Multiple Ins. companies are wanting to process only 1 unit. PLEASE HELP ME WITH THIS ISSUE!!!!

CPT Code(s): 87481x4

Test Includes: Candida albicans, Candida tropicalis, Candida parapsilosis, & Candida glabrata

Any help or advice would be greatly appreciated!! Thank you!
 
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Hello, How is this reported on the claim form? Did you list 87481 five times? Per AMA CPT, for multiple specimens/sites use modifier 59. For repeat laboratory tests performed on the same day, use modifier 91. If so, Medicare is still paying for 1 unit? I would call Medicare and find out why.
 

I would like to add something to this please:​

No, your information is CLEARLY inaccurate in my opinion. When dealing with Medicare it really and truly is all about the X- modifiers rather than the - 59 modifier. Some coders sometimes do not knowing better to apply the correct one (X- modifier) and you need to to do redeterminations all day long and all day strong. If you use Modifier 59 I feel like you have to perform "redeterminations" to get paid and send them the notes. Whereas I feel that if you had possibly applied Modifier XS or otherwise depending on documentation and so forth it may have been paid upfront rather than denied.
AND again, with Modifier 91 that is like SO ABSOLUTELY clearly incorrect here, you only use that if it was clearly a repeat lab (THE EXACT SAME LAB) performed earlier in the day of service. If your facility has these "internal policies" I would be reaching out to your compliance department to review those policies. How was this billed out seriously, We, have a very short window of opportunity to do a "redetermination" (6 months), or correction that requires a reopening from the DOS (day of service).
I'm unsure who to address at this point. You bill first line 87481 with no modifiers for the first specimen and the remaining lines with 87481 with XS modifier? From my days working laboratory charges long ago that was one of the solutions for a company I had worked for. They unnecessary allowed Modifier 91 on subsequent charges (same CPT) rather than 59 (before the X modifiers were created) I will clearly never add Modifier 91 ABSOLUTELY EVER unless it was a "true repeat". Be on top of this craziness.
Thank you for listening,
Dana Chock, CPC, CAPC, CHONC, CPBA, CPB, RHIT
 
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