Major Payors editing 99152 for GI codes
This has become an issue for us as well, I don't think BCBS are following the codes; maybe they dont know it changed; but if they want a modifier use it; but they should be paying for it since it is NOT inclusive in the codes anymore.
We have multiple major payors editing 99152 for GI codes. I checked the NCCI tables and on 7/1/17, Medicare added 99152 as an edit to multiple GI codes:
CPT only copyright 2016 American Medical Association. All rights reserved.
Column 1 Column 2 *=in existence Effective Deletion Modifier PTP Edit Rationale
prior to 1996 Date Date 0=not allowed
*=no data 1=allowed
45378 99152 20170701 * 1 CPT Manual or CMS manual coding instructions
My understanding of this is that Medicare NCCI edits apply to Medicare only and this is correct for CMS because they require HCPCS code G0500 when moderate conscious sedation is performed with a GI procedure. For Medicare patients the provider will just need to crosswalk 99152 to G0500.
Commercial payors have adopted the NCCI edits but do not allow G0500, so the McKesson claim editors I checked are requiring a modifier to override the edit.
Is this what others are seeing?
Since the separation of the sedation from the codes it used to be bundled into in January, 2017, CPT instructs providers to bill 99152 and there are no modifiers mentioned in the guidelines. The only available modifier is 59 to override the edit. This seems wrong for commercial payors to use CMS manual coding instructions without allowing use of G0500 we're forced to use 59.
Has anyone seen anything published about this situation? It's already challenging to bill a colonoscopy without this complication.