Wiki 53 modifier

[jgossett]

One of my docs was starting a cataract surgery and noticed the retrobulbar hemorrhage. He ended the procedure. I coded this with a 53 modifier. The insurance is Palmetto Medicare and is saying not medically necessary. Any suggestions? I have tried a couple of different things but cannot get it paid.

 

[Deborah Marsh]

Hi - The ophthalmology forum members may be able to offer some help, too, if you haven't posted there yet. Perhaps include the CPT and ICD-10-CM codes reported since you mentioned the message is "not medically necessary."

 

[jgossett]

thanks for the advice, but I cannot locate an ophthalmology forum....as for the CPT and ICD 10 cm codes.....66984 and H25.812. Any help is appreciated. Medicare paid the procedure when it was repeated and completed. I just have this charge sitting out there and if I need to adjust it because the 53 modifier won't get paid, that is what I am needing.

 

[Deborah Marsh]

The ophthalmology forum is about 6 from the end on https://www.aapc.com/discuss/ - Hope that helps! Looks like Palmetto has requirements like a "concise statement" for mod 53. Maybe one of those is the issue? https://www.palmettogba.com/palmetto/jjb.nsf/DIDC/8EELF98874~Claims~Modifier Lookup

 

[twizzle]

Really, if they started the procedure but didn't actually perform any of the elements per the CPT code, it would not be a billable service. You didn't say at what the stage the procedure was terminated.

 

[jgossett]

Thanks so much for your help.