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99152 Denials by Commercial Payors on GI procedures

T

tfischer

Guru
Messages
100
Location
Warsaw, OH
I have been receiving denials from several commercial payors on 99152 when billing with GI Endoscopic procedures. Payors are stating it's bundled with primary procedure, but I was of the understanding the MCS part of the procedure was pulled out of the primary procedure value as of January 1, 2017. Has anyone else been experiencing denials on 99152 with GI procedures? If so, have you had an luck with resolving?
 
tfischer said:
I have been receiving denials from several commercial payors on 99152 when billing with GI Endoscopic procedures. Payors are stating it's bundled with primary procedure, but I was of the understanding the MCS part of the procedure was pulled out of the primary procedure value as of January 1, 2017. Has anyone else been experiencing denials on 99152 with GI procedures? If so, have you had an luck with resolving?
Click to expand...

I am having a similar issue with our claims scrubber saying a modifier is needed on 99152? This just started in 2018?
 
Anesthesia/Conscious Sedation GI denials

I am also having trouble with them 99152 denying as bundled on GI endo procedures, but CCI edits state modifier allowed so I billed with a 59 on 99152 and it denys as invalid modifier combo.

We are also having problems with the new anesthesia-GI codes denying as bundled with the GI ENDO procedures and no modifier allowed. Is anyone else having this issue or have any insight to it. I do not understand why they created new Anesthesia GI codes if they were just going to bundle with no modifier allowed.

Thanks for any input!
 
Moderate Sedation and GI Bundles

This has just started Jan. 1 2018. Our claims won't go thru the scrubber without the modifier, haven't received any denials yet though. Has anyone received any information on this. No one I've spoken with has any idea?
 
99152

Having the same issue. 99152 denies as bundled but when I add the 59 modifier, it states it is an invalid modifier combo. I am currently trying the XU modifier, but haven't gotten anything back yet. Previously BCBS of OK did not recognize the X modifiers on anything, they wanted the 59.
 
We are getting denials without appending modifiers and the payors are suggesting us to append them. As a group we listened to a Webinar that addressed this exact issue. The presenter stated we should not be appending modifiers as it's inappropriate. If anyone has any insight or resolution to this, I would love to hear from you! =)
 
99152

When you listened to a webinar on this issue did they explain WHY a modifier should not be used? We still do not have this resolved...however when we bill the G0500 to Medicare they pay it, no problems. We have talked with our BCBS provider representative and all she tells us is if we disagree with the determination to appeal it.:(
 
Also seeing the 99152 denials

We have been seeing denials from Cigna, Geisinger, and Harvard Pilgrim for the EGD/Colonoscopy codes charged with the 99152 when mod sedation performed by the provider. Each payer is denying for different reasons. Mod 59 is appropriate for the 99152 per CodeCheck in NThrive. I also would like to know why the webinar mentioned in this thread said the mod 59 was inappropriate? Anyone have a copy of the webinar powerpoint (if there was one) with the information on it and the source?
I'm glad to know it's not just us, but it would be great to get a concrete answer from the payers.
Has anyone been able to resolve this with any of the payers?
 
99152 Denials by Commercial Payors on GI Procedures

I went back to view the Cardiology slides and that information was not physically added in the slide--it was verbally communicated by the presenter. However, I had a couple coders attend the OHIMA meeting last week and the MCS question was brought up. The presenter at this conference didn't mention a modifier was required/appropriate, but did state if the denials are from the physician
side, they need to be appealed. Since the moderate sedation code were broken out of codes just over a year ago, there were many denials being received, however, these codes should both be reimbursable on the physician side.

Also, there is a webinar through ASGE on Tuesday, April 17th that has Moderate Conscious Sedation specifically listed as a topic. Unfortunately, our organization will not pay for the webinar, so if anyone is listening in on this, I'd love to hear any feedback they provide.
 
Cpc

I bill for a GI and it is a hit or miss on 99153(ea additional 15 min) whether or not commercial insurance will pay. Medicare will only pay for the G0500 and 99153 Medicare pays to facility as my provider performs procedures in a hospital outpt setting and not his own office. It was my understanding that G0500 (initial 15 min) is to be billed if the provider is GI specialist and 99153 for ea additional 15 min and no modifier needed as it is considered an add on code. However, we receive more denials than payment and we do not know why 99153 does not pay-It feels like its at the discretion of the insurance whether they pay or not. Blue Cross/Blue Shield merely states they do not recognize any moderate sedation codes. Why did they even change? This has created more work and more follow up on our end. I will be watching this feed to see if anyone has a solution.

Seeking a resolution. Thanks for letting me rant.

Noelii Carr CPC
 
99152

The appropriate modifier for all conscious sedation codes is 47. Most payers will accept these codes and modifiers, however Medicare and Medicare Advantage plans will not accept the 47 modifier and require you bill conscious sedation with G0500. Medicaid and managed Medicaid does not accept any conscious sedation codes.
 
99152 Denials by Commercial Payors on GI Procedures

tfischer said:
I went back to view the Cardiology slides and that information was not physically added in the slide--it was verbally communicated by the presenter. However, I had a couple coders attend the OHIMA meeting last week and the MCS question was brought up. The presenter at this conference didn't mention a modifier was required/appropriate, but did state if the denials are from the physician
side, they need to be appealed. Since the moderate sedation code were broken out of codes just over a year ago, there were many denials being received, however, these codes should both be reimbursable on the physician side.

Also, there is a webinar through ASGE on Tuesday, April 17th that has Moderate Conscious Sedation specifically listed as a topic. Unfortunately, our organization will not pay for the webinar, so if anyone is listening in on this, I'd love to hear any feedback they provide.
Click to expand...

Did anyone happen to catch the webinar through ASGE yesterday?
 
G0500 is the way to code for GI only

G0500 is the only code to use. utilized box 19 the comment field for total minutes
99152 you can try and appeal make sure you are sending both the endoscopy report and nurse's log to support accuracy of time documentation
 
99152 denying with Gastro procedures

I discovered that the G0500 is on BCBS of Oklahoma fee schedule. I have been using it for commercial payers, BCBS, Cigna, Community Care etc, and it is paying!!! You all might give that a try.
Kim Boyd, CPC
 
99152 moderate sedation denials for modifier

I'm having trouble with UMR/United Healthcare with denials of the 99152 and 99153 to inclusive to endoscopies. We have some saying non-covered, inclusive to primary procedure. Sometimes they pay 99152 but deny 99153. But, other times both is denied. Recently, we appealed with notes and coding guidelines. Still denied. Any ideas why these codes aren't being recognized? Should I be adding a modifier. I'm billing Professional Services not facility.

Commercial examples
45378
99152 no modifier
+ 99153 no modifier


Surprisingly, Medicare isn't usually an issue.


Medicare examples
G0121
G0500 No modifer
+ 99153
 
Is G0500 the way to bill for 99152 for commercial carriers?

I have just started billing for a GI doctor. I am getting denied for 99152 and 99153 from all carriers.
For Medicare, I see that using G0500 instead of 99152 works.
Should I use G0500 for Commercial Ins also?
Thx
Ken
 
klobo said:
I have just started billing for a GI doctor. I am getting denied for 99152 and 99153 from all carriers.
For Medicare, I see that using G0500 instead of 99152 works.
Should I use G0500 for Commercial Ins also?
Thx
Ken
Click to expand...

Many commercial carriers follow Medicare with G code usage. Here is example Blue cross of Massachusetts requires the G code when reported with GI procedures:

https://provider.bluecrossma.com/Pr...8590e11ea/Gastroenterology_payment_policy.pdf

See the following comment next to the moderate sedation codes:

All codes continue to be subject to standard claim edits. For example, 99152 will deny when billed with gastroenterology procedure codes. Use HCPCS code G0500 to bill moderate sedation with gastroenterology procedure codes.
Click to expand...
 
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