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Billing 28112

A

aschaeve

Guru
Messages
161
Location
Fond Du Lac, WI
28112 reads osectomy other metatarsa head (second, third or fourth). My question is, can this only be billed once or can it be billed multiple times.

Thanks,

Alicia, CPC
 
If you are only billing for the 28112 you should bill 1 unit of 28112 with just an anatomical modifier. The subsequent procedures would need to be billed with modifier 51 because the code is subject to multiple procedure reductions. I would suggest you bill each additional procedure on a separate line with 1 unit and append modifier 51 and I would include the appropriate T anatomical modifier.

Also, the MUE units for a physician for this code is 4 units per date of service. So your billing would look something like this with 1 unit per line:

28112-T1
28112-51,T6
28112-51,T7
28112-51,T8

I work for an insurance company, and this would be how my company would expect to see this scenario billed. You don't technically have to bill the T anatomical modifiers, but it tells the insurance company which toes were treated, and the charges are less likely to be potentially denied as duplicates on the lines billed with modifier 51 because you have clearly told us which toes were treated.
 
I was trained that the toe modifiers were for the toes, not the foot/metatarsals. Has this changed?
And none of the payers I work with accept the -51 modifier anymore, but maybe that's a geographical thing, so we would use the -59, -RT modifiers.
 
According to Encoder Pro Payer Professional, the T modifiers are cross walked as acceptable modifiers for 28112, so that is why I referenced them in my response.
 
Old post that has taken on new life. However, the T modifiers are "normally" reserved for phalanges. Some payers want the T mods on metatarsals. It depends. As for the 51, it doesn't make sense to append a 51 modifier to multiple lines of the same code because they all have the same value. So, it doesn't matter which line gets the multiple procedure reduction. I agree with nsteinhauser that 51 is pretty much not used anymore. Medicare tells us not to use it at all. Most claim systems now automatically rank the codes in RVU order and apply the multiple procedure reduction appropriately. That doesn't mean we shouldn't submit the claim with them ranked correctly when coding multiple CPT of different RVU, but modifier 51 is almost obsolete at this point. Some payers may still want it. "Technically" if going from a pure coding book or class standpoint you would still use it, but that's not real world.

It may make sense in the example above to use the T mods for four different MT heads to explain which ones.
My opinion, if you were doing toes 2-4 on one foot, would be 28112, 3 lines, w/ the T mods. No 51s, no 59s. Why would you append a 59? Nothing bundles. It's not a needed modifier in this case. You may even get it through without the T mods. Depends on the payer, some would gum it up and want the Ts while others might say no we want RT/LT (which doesn't make a lot of sense but...). The ICD-10 would show if it was RT/LT.

Note: Medicare doesn’t recommend reporting Modifier 51 on your claim; our processing system will append the modifier to the correct procedure code as appropriate.
 
I think it is important to know which of your insurance companies expect you to append modifier 51 and which do not. The insurance company I work for expects providers to append modifier 51 when applicable as our system doesn't automatically reduce multiple procedures and what happens is that a post-payment audit is performed, and the overpayment is identified and then the claim is adjusted which is a hassle for the everyone involved IMO.
 
CBLENNIE said:
If you are only billing for the 28112 you should bill 1 unit of 28112 with just an anatomical modifier. The subsequent procedures would need to be billed with modifier 51 because the code is subject to multiple procedure reductions. I would suggest you bill each additional procedure on a separate line with 1 unit and append modifier 51 and I would include the appropriate T anatomical modifier.

Also, the MUE units for a physician for this code is 4 units per date of service. So your billing would look something like this with 1 unit per line:

28112-T1
28112-51,T6
28112-51,T7
28112-51,T8

I work for an insurance company, and this would be how my company would expect to see this scenario billed. You don't technically have to bill the T anatomical modifiers, but it tells the insurance company which toes were treated, and the charges are less likely to be potentially denied as duplicates on the lines billed with modifier 51 because you have clearly told us which toes were treated.
Click to expand...
With most payers, the 51 modifier is a system generated one at payer level. Only a handful of Medicaid plans want the 51 added. In this posted scenario, the RT or LT modifier along with the XS or 59 modifier on lines 2,3,4 would be the most appropriate.
 
CBLENNIE said:
I think it is important to know which of your insurance companies expect you to append modifier 51 and which do not. The insurance company I work for expects providers to append modifier 51 when applicable as our system doesn't automatically reduce multiple procedures and what happens is that a post-payment audit is performed, and the overpayment is identified and then the claim is adjusted which is a hassle for the everyone involved IMO.
Click to expand...
51 modifiers are payer system generated...there are very few that require the coder to add the 59.
 
CBLENNIE said:
I think it is important to know which of your insurance companies expect you to append modifier 51 and which do not. The insurance company I work for expects providers to append modifier 51 when applicable as our system doesn't automatically reduce multiple procedures and what happens is that a post-payment audit is performed, and the overpayment is identified and then the claim is adjusted which is a hassle for the everyone involved IMO.
Click to expand...
Good point!
 
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