Question Billing to Medicare for physician fee schedule

SharonCollachi

True Blue
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Clovis, CA
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I think you're going to need to clarify your question. Without further information, the answer to "how to bill" for anything is, code/bill what was performed, add the appropriate modifiers, the pertinent diagnoses, and send the claim on its way.

However, I don't think that is the answer you were looking for.
 
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Roselle, Illinois
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I work for lab company and we are getting denied claims for these codes. Our carrier said to contact original carrier So wondering how to bill for these codes? Do they need special modifier?
 

sls314

Guru
Local Chapter Officer
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Toledo, OH
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I work for lab company and we are getting denied claims for these codes. Our carrier said to contact original carrier So wondering how to bill for these codes? Do they need special modifier?

Your carrier said to contact the original carrier - does that mean that the patient has another insurance primary? What specifically is the denial code being used?

To answer your other question, yes often those codes do need modifiers depending on the circumstances - how many units you're billing, what combination of codes you're billing on the same claim, etc.

Can you give a specific example of codes from one claim? It could be an issue with the MUEs or the NCCI edits. Without more information, we can't really speculate.

However, if you give an example from one specific claim, we might be able to walk you through what's causing your difficulty getting reimbursed.
 
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Roselle, Illinois
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Example would be:
1) Pt had lab services done for UA reflex w/ culture, and non-gyn cytology, we billed to Medicare with Dx code N390 and CPT code used 88173 used with modifier 90. (CPT is under physician fee schedule) denial was for CPT 88173.

2) Pt had lab services for CMP, lipid, cbc w/ diff, (immunoassay, Analyte - used modifier 90), (Immunossay, Qunt, RIA - used modifier 59) and (Anti striated muscle AB - used modifier 90). CPT's for all labs used are 80053, 80061, 85025, 36415, 83519, 86255. We billed to Medicare primary and pt also has BCBS secondary.
Denial was for CPT 83519.

Both the claims got rejected with denial code N104 (this claim/service is not payable under our claims jurisdiction area. you can identify the correct medicare contractor to process this claim/service through the CMS website cms.gov)

Thank you
 
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