1. A

    Wiki Texas Medicaid J Code Modifier

    Hello, Got a denial from Texas Medicaid for J1100 & J0696 with the following: 00211: Injections when alternative drug or route is possible require modifier. Looking for help!
  2. C

    Wiki Modifier XU

    Hello, can anyone provide examples when you would use modifier XU. I have googled this and can only find one specific example. I would like to know when coding CPT procedures, what kind of procedures would you apply modifier XU to a CPT code?
  3. T

    Wiki Is a KX modifier needed?

    Is a modifier needed when billing J9190 (5FU) with G0498 for chemotherapy infusion?
  4. A

    Wiki Modifier 76 clarification

    I'm getting caught up in the terminology of 'repeat procedure' for the definition of modifier 76. My understanding is that that very literally means a repeated procedure, as in same site/same procedure. For example 20605 performed in the LT naviculocuneiform joint, the LT talonavicular joint...
  5. N

    Wiki 88323 clarification. Please help!

    I work for a pathologist that receives material from other physicians. Sometimes for interpretation or slide prep. Oftentimes both. I have been running into an issue with 88323. We receive specimen and we prep the slides and read them. The provider insists that we can bill 88323-26 and 88305-tc...
  6. RaveenaS

    Wiki Humana Denial for Missing Hernia Modifier {Redacted Op Provided}

    Humana has sent a letter explaining the claim is denied for missing a required modifier to the primary procedure code. I've reviewed this so many times myself, with my coding team, and I've contacted Humana but the rep state they cannot provide any coding recommendation as they are not part of...
  7. S

    Wiki Assisting Surgeon for WC claims

    Hello, My Provider is a CST (certified surgical tech) & CSFA (certified surgical first assist). She has been assisting with some WC claims and we are having issues with getting paid. We bill with an -AS modifier for ALLLLLLLL carriers. When I bill them to WC it gets denied for: Invalid...
  8. D

    Wiki How to Bill for a Resident as an Assistant Surgeon for a C-Section

    Hello, Wondering if anyone has any input on this. How would you bill the resident charges if they were the assistant during a c-section and their supervising physician was the primary surgeon? The primary surgeon would be the billing provider on both claims which is not possible since the...
  9. K

    Wiki Billing J0129 to Medicaid

    Hi everyone, I work in a Rheumatology office where we perform several injections and infusions weekly. As of recent, Medicaid has denied J0129 Orencia as a non covered charge due to the fact it was recently added to the SAD list. Any advice on how to bill this would be greatly appreciated, as...
  10. A

    Wiki 62321 and J1100 denial

    We have been receiving denials from Blue Shield for missing modifier on 62321 but J1100 is paid. Is J1100 included in 62321? or would I have to bill a 59 modifier on 62321?
  11. J

    Wiki Modifier 27 help

    Hi all! I'm looking for resource material regarding the use of Mod-27. I code for an ED with affiliated Primary and Specialty Care offices and Walk-In's. At some point, someone in my organization advised we could not use Mod-27 with ED E/M's when a patient has an additional outpatient visit that...
  12. C

    Wiki Medicare denying claim for missing procedure modifier

    Last Update: My supervisor says she doesn't want me doing denials. At least, not yet. It was a co-worker who had asked for my help in getting it done. I had wanted to try doing denials anyway, but since I was dropped into the deep end without a float, I felt frustrated and stuck when the...
  13. KStaten

    Wiki Repeat Injections with E/M Codes

    Greetings Fellow Coders! :) Scenario: A new patient is evaluated and found to have OA of the left knee. On that visit, the physician decides to perform an injection and bills an E/M (99203) with a modifier 25. At that visit, the physician does not "plan" another injection. If the patient...
  14. J

    Wiki DME Modifier

    Anyone familiar with a modifier to use with DME HCPC's that signifies that patient opted to pay out of pocket for an upgrade on a piece of medically necessary equipment? I want to bill for the medically necessary item but also report to payers when a patient chooses the add-on's.
  15. K

    Wiki Modifier CS? When to use?

    Hello, I am working at a physician's practice that is seeing people to be tested for covid-19. We do not bill labs, our sister hospital does, so this question is in relation to office visit charges: When we see a patient and they are tested for covid-19 do we need to use a modifier CS to signify...
  16. KStaten

    Wiki Billing 20550 (or 20551) with 20610

    Hello, Everyone! :giggle: As usual, I have a 2-part question and would appreciate your help. 1) When 20550 (or 20550) is being billed with 20610 for two separate body parts, which modifiers would be used? Example: tendon sheath injection, left elbow bursa injection, right knee 2) Also... I...
  17. M

    Wiki Can a modifier be added at the request of the insurer even if CMS/AMA guidelines don't require one?

    We have some CPTs that have been denied by an insurance company for "missing modifier". CPT 99291 was paid then the payment was recouped as "within global period". After our appeal, we received a letter that stated "the claim submitted did not have a modifier appended to the E/M service"...
  18. F

    Wiki Revision ACDF during global

    Patient has a fall within 2 weeks of ACDF and returns to the operating suite. New diagnosis is "mechanical complication of implant". Surgery is revision of ACDF with increased difficulty (22 modifier). My question is this: which modifier would you use? 58 - because it's more extensive than the...
  19. S

    Wiki Discontinued Procedure and repeat?

    I have a patient whose procedure was discontinued today after the administration of anesthesia, so we are billing with the discontinued procedure modifier. However, the patient is coming back in a few days again for the procedure. Do we need to bill a repeat procedure modifier or will the...
  20. K

    Wiki Modifier with screening

    UHC started denying screening codes G0444, G0443 with mod 25. I tried 59, 51 and only XU works with Medicare plans. Did anyone bypass this denial with UHC? Thank you
  21. S

    Wiki H2019 Duplicate Denial

    A client is billing for H2019 services done in two different settings for the two claims, different encounters, same patient, same date of service, same practitioner. Only difference is that the place of service code is different, the units, and the charge amount. I have suggested that they...
  22. A

    Wiki Modifier for 99080 billing TX Work comp SOMR

    Hello - Does anyone know where I can find a list of appropriate modifiers for Texas work comp. We filled out the DWC073 and DWC069 stating the patient could now return to work. We billed our E/M code as well as the 99080 but used modifier 73. SOMR has kicked it back for the procedure code...
  23. C

    Wiki 25 Modifier ONLY to be appended by certified coder?

    Hello! I am a CPC for the department OBGYN for a large medical group. just spoke with a member of management from the central billing office at my place of work, and they requested that I advise our billers that they may not append the modifier 25 to any office visit if they are not coders. I...
  24. S

    Wiki X-ray billing help!

    I'm new to an ASC facility and when it comes to x-rays (almost always performed along with a surgery), I am told that we code professionally with -26 modifier but don't bill at all for the facility side. It was explained to me that x-rays are included in the global surgery package for...
  25. C

    Wiki Obesity Preventative Counseling

    We are billing G0447 to medicare in place of the standard 99202 code. Medicare is stating we need a modifier but we can't figure out which one. We have tried 33 and got denied already. We use modifier 25 for the 99212 code already. What modifier can we use to get reimbursement?
  26. A

    Wiki Modifier XE vs. 59

    I'm looking for guidance on when to use modifier XE vs. modifier 59. For example, an ABA client is seen in the morning for 60 mins for behavior treatment (0364T - first 30 mins & 0365T - additional 30 mins). The client is then also seen later that day for the same service (0365T). Services are...
  27. K

    Wiki Pyelogram modifier - Md or radiologist

    Hello, I am trying to figure out how apply a modifier for a pyelogram 74420 that was done during an inpatient procedure by the MD and then sent to the radiologist for reading. Does the MD get a 26 for performing the pyelogram? What does the radiologist charge for his reading? In a...
  28. E

    Wiki spinal fusion HELP PLEASE

    So my Ortho doc performed a L5-S1 spinal fusion, my problem is that he was also a Co Surgeon in the approach, Anterior Retroperitoneal Exposure, and then went on to do the fusion, CPT code 22558. Normaly I would just code this as 22558-62, but that is when the one surgeon does his part, and my...
  29. L

    Wiki Help with Modifier for cpt 61635 & 61630

    We recently got a new Medicare MAC which is Palmetto. I am now getting denials for cpt 61630 & 61635 stating I am missing a required modifier. This wasn't required with our old MAC. I've talked to Palmetto several times to no avail as to where to look for the appropriate modifier. I know these...
  30. W

    Wiki Modifier FL?

    I am a CPC but am currently working for a health system doing claim denial follow up. Our coders are telling me that modifier FL is appropriate for CPT code 90471. I don't find anything indicating that modifier FL exists. Has anyone else heard of this?
  31. A

    Wiki Resident Surgery

    Hello All! Looking for help clarifying surgical assist involving residents. I'm not 100% comfortable and therefore I keep doubting and confusing myself. First off, if a resident is the first assistant, I understand we can not bill for there service but would it be necessary to add a GC...
  32. F

    Wiki Completion Mastectomy

    This patient had a mastectomy in 2012 and had a recurrence and we performed a completion mastectomy with reconstruction. Do we need to append any modifiers to indicate that this is a completion procedure? Indication for Surgery xxx is a pleasant 51 year old female with history of Stage II...
  33. B

    Wiki 99222 and 32555?

    Help! I'm hoping someone may be able to shed some light on a billing question I and my boss have. :) We admitted a patient on 12/27/17 for Shortness of Breath (R0602), Abnormal Coagulation Profile (R791), Sepsis (A419), Hypokalemia (E786), Essential Hypertension (I10), Thyrotoxicosis (E0590)...
  34. K

    Wiki Modifier 78 for return to surgery by different MD for related problem

    Please help to clarify what modifier, if any is appropriate for return to surgery post op, during the global period for complications of original surgery by a DIFFERENT surgeon. Since it is not the original surgeon, would a modifier 78 still be required? If the second surgeon is not in the same...
  35. daedolos

    Wiki Anthem Modifier 25 Policy

    Just was informed through the Navicure webinar on Key Performance Indicators that Anthem is instituting a 25 modifier reduction on claims for all E/M services for global periods under 10 days. It will affect the visits regarding care for pain management (injections) and fracture aftercare. Was...
  36. K

    Wiki HELP! Medicare G Modifiers: When to use which one?!

    Hello, I work in a public health agency and our contract with Medicare is as a immunization roster biller only (we can only bill/receive payment for Influenza and Pneumococcal vaccines). Since we are a public health agency, we do not turn away a patient with Medicare if they want something other...
  37. H

    Wiki Office Visit & Skilled Nursing Facility

    I am looking for insight - I work for a healthcare system which includes many different primary care and specialty services in the office setting. Some of our offices see patients who happen to be in a skilled nursing facility. The patients are being brought from the SNF to the provider's office...
  38. J

    Wiki Modifier 25 with X-rays? AAPC practice exam says it is required?

    Maybe I am missing something... I am trying to clarify the issue. I was taking the AAPC module that I purchased: Specialty Practice Exam COSC™ And on Case 20 it goes over a basic office visit for knee pain. All that is done is an e/m and an x-ray, 73562. Question three asks if a modifier...
  39. J

    Wiki Medicare - modifier for same day visit, different provider

    A patient has come in for treatment code 97140, and we later found out they went to another provider on the same day with different specialty who billed the same code. Which modifier would be appropriate for this to resubmit? Thanks.
  40. R

    Wiki Global Period Modifier Scenario

    Patient had an eye surgery done that has a 90 day global period. Patient then had a second procedure done on same eye 2 weeks later (modifier 58 was used since it was staged) but this second procedure only has a 10 day global period. Patient is about to have a third procedure done on the same...
  41. K

    Wiki 27602 bilateral

    There is a patient with diagnoses M79.A21 and M79.A22, one for each side of the body. The procedure 27602 was performed bilaterally. I am trying to figure out if I report the CPT on one line with a 50 mod and list both dx codes (I think this is correct), or if I assign each dx to two separate...
  42. M

    Wiki Modifier with 81003 and go477

    If we are doing a Drug Screen and a Urine dip with a possible UTI or other Urine issues, Is there a modifier that can be used showing they are totally separate. We have used 59 and 91 and both were denied. thank you for any help...
  43. M

    Wiki Modifiers with Level 5, prolonger service, fingerstick, and flu vax and admin

    Hi all, One of our providers is billing: 99215 - level 5 established patient e/m 99354 - prolonged service 82962 - glucose fingerstick 90661 - flu vaccination 90471 - vaccine administration What I am confused on is what modifiers to use in this situation, and where. I believe 59 would go on...
  44. M

    Wiki Breast biopsy modifier

    Hello! Would you be able to give advice on the proper modifier to use for a breast biopsy that has been started (patient was prepped, injection of dye given, localization images performed), but the focus of the biopsy was not located, therefore that portion was not performed?
  45. P

    Wiki Readmission during postoperative period

    Hello! Here's the scenario: Patient is admitted for appendicitis and has an appendectomy (90 day global). The patient is discharged and sent home. The patient returns to the ER 2 weeks later for abdominal pain and is admitted for suspected abdominal abscess. Question: Would all of the E/M...
  46. J

    Wiki 64483 - 64484 Payer Denial

    Working in pain management. We bill the following combination often with no issue. However, an Arizona Medicaid plan is denying the 64483 and 64484 with "Procedure code inconsistent with modifier or required modifier is misssing". Upon query at the payer, they verified the modifiers submitted...
  47. J

    Wiki When billing codes 33249 and 93461-26?

    I am new to cardiology coding and need some help. Our doctors do the coding and I billed 33249 and 93641-26 together to Medicare and they responded with non covered for medical necessity. I am not sure if a 59 modifier should also be placed on the 93641-26 or what to do from here. Any...
  48. N

    Wiki can you bill ER facility side

    If a 2yr old comes and has fentanyl intranasal administered do you charge 99283 with 99143 ? if so do you apply a modifier -25 to the EM? I am getting a rejection. thank you
  49. T

    Wiki Modifier U2

    Can someone explain the purpose of the modifier U2 on cpt 59514. When I look it up it only says Medicaid level 2, I want to understand so I will know to code with them or not.
  50. T

    Wiki Modifier 57 - abdominal adhesions

    Pt having 58720 and during surgery realized that the pt had dense pelvic and abdominal adhesions. They used 58720-57 and 58740. I am not sure that modifier 57 is correct. Lysis of adhesions is usually an included procedure unless it adds significant additional work. The notes state that they...