Wiki 49568 mesh implantation bundling to wrong hernia repair

[kgmcewen1]

BCBS is denying payment on 49568 (mesh implantation). I billed for CPT codes 49560 (incisional hernia repair), 49585 (umbilical hernia repair) with an XS modifier to indicate a different surgical site, and 49568 (mesh). Both hernia procedures were paid, but they won't pay the mesh code because they say they have bundled it with the hernia that does not allow for separate mesh coding, (the 49585). What modifier would I use to have the insurance not bundle the mesh with the 49585 and appropriately pay it as an add on to the 49560? Thank you!

 

[ch81059]

Same Issue

I have been having the same issue with a Humana commercial claim and it's very puzzling because I've been doing billing and coding for general surgery for 18 years and we've only recently started having this problem. I have a claim right now that I submitted with the exact same codes. They paid both hernias but continually deny the mesh placement no matter what modifier is used. I billed the 49585 with an XS modifier and even resubmitted a corrected claim with an XS modifier on the 49568 as well just for kicks, but still denying. And the diagnosis code for the umbilical hernia isn't indicated on the line for 49585. We used to be able to send the 49585 with a 59 modifier (before the X modifiers) and get it paid with no problem. I have read that others are having this problem and since the mesh is higher reimbursement than the umbilical hernia, they are choosing to bill the mesh and not bill the umbilical hernia repair at all. That may be something that we will have to do in the future but I appealed to see if we can get it paid. I'll let you know what I find out.

Incidentally, is the BCBS plan for your claim Medicare replacement or commercial?