Wiki 97124 with mod 59

[aime1369]

I am having some trouble getting 97124-59-GP paid through Triwest Choice program if anyone can help? The code has been pre-authorized by them however it is being denied per Medicare "line is being disallowed because it's procedure code is unbundled per Medicare". We are billing this in conjunction with 98941 and 98943. Can anyone point me in the right direction for this Medicare guideline so I can attempt to appeal this if possible. Thank you so much!!

 

[pattiland]

I am having some trouble getting 97124-59-GP paid through Triwest Choice program if anyone can help? The code has been pre-authorized by them however it is being denied per Medicare "line is being disallowed because it's procedure code is unbundled per Medicare". We are billing this in conjunction with 98941 and 98943. Can anyone point me in the right direction for this Medicare guideline so I can attempt to appeal this if possible. Thank you so much!!

Medicare will not pay for an extremity adjustment 98943 or massage therapy. Check with your local MAC and LCD. The CPT codes covered are very clear. I'm not sure what the Triwest Choice progam is? If it is a Medicare supplement, it may pay. If it is a Medicaid insurance, you will have to find out from them how to forward the Medicare denial to get your claim paid.

 

[sherifrost]

You will need to code the GP with an XE if the service was separate. Triwest will not recognize the 59.

 

[rachaelwilleford]

First, authorization is never a guarantee of payment - only of medical necessity. I know this is repetition of every disclaimer known to man, but it bears repeating. Secondly, Medicare uses the X based separately identifiable modifiers over the 59 modifiers now. Tricare uses Medicare guidelines to edit payments.