Wiki Anatomical Modifer for CPT 93459-26

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pfilson

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Hello,

Texan Plus is denying CPT 93459-26 for lack of anatomical modifier. They are citing Pub. 100-20
Transmittal: 1136, Date: November 1, 2012, Change Request: 8111 as the policy from CMS they are following.

B. Policy:
Each NCCI edit has a modifier indicator of 0, 1, or 9.A modifier indicator of 0 indicates that an edit should never be bypassed even if an NCCI-associated modifier is utilized on the claim.That is, the column two code of the edit must be denied.A modifier indicator of 1 indicates that an edit may be bypassed if an appropriate NCCI-associated modifier is appended to the column one and/or column two code on an NCCI edit.That is, the column two code of the edit may be paid if an NCCI-associated modifier is appended to an appropriate code of the edit pair.A modifier indicator of 9 is assigned as a placeholder for edits that have been deleted.
The current NCCI-associated modifiers are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, 25, 27, 58, 59, 78, 79, and 91.
Additional modifiers shall be added to the above list of NCCI-associated modifiers that will allow an edit with modifier indicator of “1” to be bypassed when the modifier is utilized correctly. These modifiers are LM (left main coronary artery), RI (ramus intermedius coronary artery), 24 (unrelated evaluation and management service by the same physician during a postoperative period), and 57 (decision for surgery). Refer to Attachment A (Medicare Claims Processing Manual, Pub. 100.04, Chapter 23, Section 20.9.1 and 20.9.1.1) will be updated in the near future to include these new NCCI asociated modifiers.

These denials just started within the past two weeks.

Has anyone else encountered this issue?

Thank you,
Pam
 
pfilson said:
Hello,

Texan Plus is denying CPT 93459-26 for lack of anatomical modifier. They are citing Pub. 100-20
Transmittal: 1136, Date: November 1, 2012, Change Request: 8111 as the policy from CMS they are following.

B. Policy:
Each NCCI edit has a modifier indicator of 0, 1, or 9.A modifier indicator of 0 indicates that an edit should never be bypassed even if an NCCI-associated modifier is utilized on the claim.That is, the column two code of the edit must be denied.A modifier indicator of 1 indicates that an edit may be bypassed if an appropriate NCCI-associated modifier is appended to the column one and/or column two code on an NCCI edit.That is, the column two code of the edit may be paid if an NCCI-associated modifier is appended to an appropriate code of the edit pair.A modifier indicator of 9 is assigned as a placeholder for edits that have been deleted.
The current NCCI-associated modifiers are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, 25, 27, 58, 59, 78, 79, and 91.
Additional modifiers shall be added to the above list of NCCI-associated modifiers that will allow an edit with modifier indicator of “1” to be bypassed when the modifier is utilized correctly. These modifiers are LM (left main coronary artery), RI (ramus intermedius coronary artery), 24 (unrelated evaluation and management service by the same physician during a postoperative period), and 57 (decision for surgery). Refer to Attachment A (Medicare Claims Processing Manual, Pub. 100.04, Chapter 23, Section 20.9.1 and 20.9.1.1) will be updated in the near future to include these new NCCI asociated modifiers.

These denials just started within the past two weeks.

Has anyone else encountered this issue?

Thank you,
Pam
Click to expand...

Did you do an intervention after the left heart cath w/ bypass grafts? 93459 should not need a modifier if it's a diagnostic procedure.
Thanks,
Jim Pawloski, CIRCC
 
i am also getting these denials for cath's what is up with that there is no ANATOMICAL modifier's:confused: with heart caths??? im very confused
 
That certainly is odd. Does this happen with any one particular insurance? I would give them a call. Maybe this was a data programming error which nobody at the insurance would notice until somebody called.
 
Recently started with Fidelis (Medicare Advantage) and Today's Options here in NYS a couple months ago. Those carriers must have had some type of update on an edit that is erroneously denying the claims. They are telling me the anatomical modifier is either the LC, RC, LD, LM or RI. Working with provider reps to do project to pay claims, in the mean time I have been appealing them giving them the documentation from the AMA book and they have been paying. More work for us to get a clean claim paid! Interesting that Medicare is still paying as they should, hopefully working together we can get this corrected for all the carriers in each state.
 
Gateway wanting vessel modifiers on cath codes

Hi...we are getting the same denials from Gateway MA and Gateway MC (Pennsylvania). They want the LD,LM,RC,LC, and RI. Very frustrating. Sandy
 
Molina Medicaid and Scott & White denying cath for missing anatomical modifiers

I have a denial from both Molina Medicaid and Scott & White because we did not use either the LC, LD, LM, RC, or RI modifier for a 93458 (Left heart cath). Has anyone had success in appealing these?
 
Wisconsin here.
I've also been getting denials. Although I do not see what exactly comes from the insurance company as we have our own billing department that enters the actual charges that I Code out. Has anyone heard anything as to why this is happening? I don't even know where to find information on any insurance updates and when this took effect. When the doctor does a cath say 93458, its a left heart cath. So that would be LT. If they go and look at the LD, LM, LC are we supposed to add ALL those modifiers or what?

So frustrating!
 
Happening also with Molina Medicare Options MedAdvantage is Washington State

One rep at Molina said that "the state" had come in and audited them and required the hard stop edits and they cannot send claims back for review. Providers must send corrected claims or appeals. I've had two in two days and haven't yet had a response on the appeals.
 
Update - Molina MedAdvantage of Washington

I sent an email to the provider rep at Molina and received a reply today. It appears that they've already resolved the issue and that the "anatomical modifiers are not mandatory for heart catheter procedures at this time."

If anyone wants a copy of the letter I sent to Molina please email me.
 
I'm from NY and recently been getting denial for the same reason. I resubmitted two claims with the XU modifier (93458,26,xu). I'll follow-up on it in 2 weeks and will inform with my outcome.
 
Anatomical Modifier and Anthem Medicare

We are having this same issue with Anthem Medicare. It's only caths with no stents or other interventions. We've appealed but they upheld their original denials. Any suggestions?

Thanks!
 
hi
I am getting denials for modifier reason on caths from highmark health options insurance its in Delaware. I work for hospital so our finance dept have contacted the health option reps who found out that its their system cci edits issue which they are in fixing process and then they will run report to pay for all the caths . this is happening since march 2018 so we have many cases pending to be paid. they are paying for stent but not cath code 93458, 93459, 93455, 93454
 
Ape said:
Recently started with Fidelis (Medicare Advantage) and Today's Options here in NYS a couple months ago. Those carriers must have had some type of update on an edit that is erroneously denying the claims. They are telling me the anatomical modifier is either the LC, RC, LD, LM or RI. Working with provider reps to do project to pay claims, in the mean time I have been appealing them giving them the documentation from the AMA book and they have been paying. More work for us to get a clean claim paid! Interesting that Medicare is still paying as they should, hopefully working together we can get this corrected for all the carriers in each state.
Click to expand...

What specific documentation are you sending form the AMA book resulting in payment from the payers? Thank you SG Coder in Cooperstown NY
 
WI response from Anthem replacement

loril1983 said:
Wisconsin here.
I've also been getting denials. Although I do not see what exactly comes from the insurance company as we have our own billing department that enters the actual charges that I Code out. Has anyone heard anything as to why this is happening? I don't even know where to find information on any insurance updates and when this took effect. When the doctor does a cath say 93458, its a left heart cath. So that would be LT. If they go and look at the LD, LM, LC are we supposed to add ALL those modifiers or what?

So frustrating!
Click to expand...

We called Anthem and were told they are looking for vessel modifiers, not RT or LT (which are inherent in the codes themselves). They are continuing to deny with submission of notes and copies of policy and guidelines and coding definitions. These appear random because we have gotten paid on some and others deny for anatomical modifier. We are continuing to move through the appeal process on the ones we do have denied for anatomical modifiers.
 
camillecoder@hotmail.com said:
I sent an email to the provider rep at Molina and received a reply today. It appears that they've already resolved the issue and that the "anatomical modifiers are not mandatory for heart catheter procedures at this time."

If anyone wants a copy of the letter I sent to Molina please email me.
Click to expand...



Hi, I am having the same issues...can you email me a copy?
thanks
 
camillecoder@hotmail.com said:
I sent an email to the provider rep at Molina and received a reply today. It appears that they've already resolved the issue and that the "anatomical modifiers are not mandatory for heart catheter procedures at this time."

If anyone wants a copy of the letter I sent to Molina please email me.
Click to expand...

I would like a copy of that email please alaina.byrne@prevea.com

Thank you!!:)
 
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