Wiki 96372 and 95117

[sparagoso10]

I have patients who come in for administration of biologics. For medicare we use 96372, however some patient also would like to get their allergy shot on the same day and I've tried billing 95117, 96372 with and without modifier 59 and it still gets denied. Is there a different modifier I should be using or is an allergy shot the same day as a biologic administration not allowed. It is also being denied with commercial insurance 95117 and 96401.....
If someone can please help I would really appreciate it.

 

[asolis84]

Try modifier 51

 

[thomas7331]

Well you can 'try' modifier 51, but I really don't think that will resolve this because to my knowledge, that modifier is not recognized by any payer for purposes of bypassing bundling denials. That is not the correct use for this modifier.

Per NCCI, 96372 does bundle to 95117, but a modifier is allowed. For 96401, there is no NCCI bundling relationship, so no modifier should be required. If payers are denying this even with the modifier 59, then what that tells you is that the particular payer is not following NCCI guidelines and may have their own bundling policies. In that case, there is a chance that they might accept the more specific XU modifier, but more than likely you are going to have to appeal this with the payer with documentation that shows that these are separate and distinct services, not components of each other, and that both warrant payment.