50 MODIFIER ADD ON CODES

MLITE2113

Contributor
Messages
15
Best answers
0
Hello All,

I am having a very hard time getting Bilateral Add on codes processed correctly by Medicare jurisdiction J8 Mac WPS GHA when there are 3 levels.
My example is Bilateral Lumbar Discectomies L3-L4, L4-L5 and L5-S1. They paid 63030-50, 63035-50 and denied the second 63035-50, 51. - Denial here-
eRemittance - WPS GHA - MAC J8 MI PART B
M20​
:​
Missing/incomplete/invalid HCPCS​
Thinking the 51 modifier was incorrect I rebilled it with 63030-50, 63035-50, 63035-50 and denied again - Duplicate
I rebilled again with 63035-50 x 2- denied again duplicate
I tried it with modifier 50,59 - Denied again
Then I rebilled it 63030-50, 63035-RT, 63035-LT, 63035-RT, 63035-LT and it denied for MUE
MUE on 63035 is 4 so 63035 x 4 is ok.
Bilateral Surgery indicator is a 1 on this code.
Modifier 50 fact sheet on Bilateral surgery indicator 1 states:
BILAT SURG Indicator "1" =150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.

There isn't a multiple procedure reduction on this code either. I'm at a loss here.............

I am having the same issue with BCBS of Michigan as well.

Any help is greatly appreciated!
 
Messages
77
Location
Sulphur, KY
Best answers
0
Hello All,

I am having a very hard time getting Bilateral Add on codes processed correctly by Medicare jurisdiction J8 Mac WPS GHA when there are 3 levels.
My example is Bilateral Lumbar Discectomies L3-L4, L4-L5 and L5-S1. They paid 63030-50, 63035-50 and denied the second 63035-50, 51. - Denial here-
eRemittance - WPS GHA - MAC J8 MI PART B
M20​
:​
Missing/incomplete/invalid HCPCS​

Thinking the 51 modifier was incorrect I rebilled it with 63030-50, 63035-50, 63035-50 and denied again - Duplicate
I rebilled again with 63035-50 x 2- denied again duplicate
I tried it with modifier 50,59 - Denied again
Then I rebilled it 63030-50, 63035-RT, 63035-LT, 63035-RT, 63035-LT and it denied for MUE
MUE on 63035 is 4 so 63035 x 4 is ok.
Bilateral Surgery indicator is a 1 on this code.
Modifier 50 fact sheet on Bilateral surgery indicator 1 states:
BILAT SURG Indicator "1" =150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.

There isn't a multiple procedure reduction on this code either. I'm at a loss here.............

I am having the same issue with BCBS of Michigan as well.

Any help is greatly appreciated!
There was a revision to our guidelines (CGS is my MAC for KY.) they do not want the modifier on the add on code anymore. Most payers have followed suit. Check your MAC.
 
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