Wiki Claim Rejected by Payor for "Potential Coding Error"?

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carlystur

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For context: Our providers regularly do Brainscopes (EEGs 95816 and Neuro Psych testing 96132) on patients who have had auto accidents or other reasons why a patient might have gotten a concussion. On one particular patient, the EEG portion was attempted twice, but the MA couldn't get any results because the patient couldn't relax due to pain. I had coded the EEG with modifier 52 due to that and received this rejection by our biller. Does anybody know what that rejection means and how it could be fixed?
 
Hello, i think the discontinued modifier may be more appropriate in this case (53 modifier) because with a imaging service its either done or not, it can be reduced in services, but it can be attempted and discontinued.
 
carlystur said:
For context: Our providers regularly do Brainscopes (EEGs 95816 and Neuro Psych testing 96132) on patients who have had auto accidents or other reasons why a patient might have gotten a concussion. On one particular patient, the EEG portion was attempted twice, but the MA couldn't get any results because the patient couldn't relax due to pain. I had coded the EEG with modifier 52 due to that and received this rejection by our biller. Does anybody know what that rejection means and how it could be fixed?
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First of all I would ask the biller why they rejected it because modifier 52 is appropriate for reduced services of a diagnostic test - that alone should not be reason for a rejection.

But if no results were able to be obtained, then it's not really a reduced services, so I think it's questionable to use this modifier. At the very most you might use the reduced services on the technical component - since there were no results to interpret, I would not bill a global or professional fee with this.
 
thomas7331 said:
First of all I would ask the biller why they rejected it because modifier 52 is appropriate for reduced services of a diagnostic test - that alone should not be reason for a rejection.

But if no results were able to be obtained, then it's not really a reduced services, so I think it's questionable to use this modifier. At the very most you might use the reduced services on the technical component - since there were no results to interpret, I would not bill a global or professional fee with this.
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Let me clarify that it was the payor who rejected it, not the biller. I stated in the title of this post that it was rejected by the payor for "potential coding error". Personally, I'm not convinced that this biller knows enough about coding in general to reject it like that. Also, we own all the imaging equipment and the provider interprets the results, if that's relevant here.
OpenClaims said:
Hello, i think the discontinued modifier may be more appropriate in this case (53 modifier) because with a imaging service its either done or not, it can be reduced in services, but it can be attempted and discontinued.
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I have changed the modifier to 53, as you say. We'll see what happens on whether or not it gets rejected again.
 
carlystur said:
Let me clarify that it was the payor who rejected it, not the biller. I stated in the title of this post that it was rejected by the payor for "potential coding error". Personally, I'm not convinced that this biller knows enough about coding in general to reject it like that. Also, we own all the imaging equipment and the provider interprets the results, if that's relevant here.
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Payers are really something these days, aren't they - denying a claim because there might be a coding error? How do they know there might be an error?
 
Well, if they tell you clearly there IS a coding error, it might be construed as them telling you how to code the claim to get paid - you know, since they're telling you it's not right :rolleyes: Logic and rationality is not their strong point for sure!
 
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