Have you received any information pertaining to this coding issue? I am in the same situation. I called Medicare, but the representative would only state that these codes are now bundled and look at the NCCI Edits.
Hi there, I think you've identified the problem with the update. You still need to show that the definitive test meets the requirements for unbundling with a modifier. 91 doesn't work because that applies to a repeat of the same test, which isn't happening here. A separate and distinct modifier might work but I could see a payer trying to argue that the definitive test isn't separate and distinct enough.
Thank you for the info! This is helpful. So far, Medicare, AARP and UHC have rejected our claims so we are now holding these claims until further notice. We've been billing all other payers until we see start to denials. I've been debating on modifier 59 or XU but based on what you are stating, 59 might not be the correct one. Let's stay in touch on this and help each other out.
Are you seeing denials on all Aetna plans or just replacement?
Thank you for posting the ACLA's letter. I hope it brings positive result.Fellow Coders: Please be advised that ACLA AND NILA have sent letters to CMS regarding this issue. ACLA Copy of letter attached. Below is a snippet:
ACLA has appreciated engagement with CMS on this matter, and we continue to urge the agency withdraw the NCCI edit policy. While CMS has offered to put a generic edit “modifier” in place on or after October 1 that would allow payment for both presumptive and definitive testing “in those circumstances when billing these codes together is allowable,” ACLA firmly believes that withdraw of the policy is essential to patient access. A modifier would lead to subjective determinations made by the Medicare Administrative Contractors (MACs) and state Medicaid agencies. Again, the association continues to urge CMS to withdraw the NCCI edit policy.
Fingers crossed that CMS will withdraw the edit policy!!
Can you update this discussion if you do receive payments/denial for Aetna w/ mod 59 please?
I'm in the same boat, I stated on another post most of my urine tests are being run through some form of Medicare. I have tried no modifier on either 80307 and G0480. I have tried appending 59 to the 8 and the G code and they are still denying. I think it's time to start testing sending these claims back through or with my MAC I can correct the claim on the portal and avoid duplicated denials.
all Aetna
I have not noticed reprocessing yet through our MAC, Noridian. I'm still very unclear as if this will be a process on their end or if we need to take action on our own.
I know I haven't yet either. From my understanding they are to reprocess claims starting from 07/01/2023 that were denied. I am growing concerns as to if we will need to take the action instead. We sent a few test claims out and are seeing how they will go.
We have sent out a few new test claims to keep track of and rebilled a few denied claims to keep track of. Hopefully we can see what happens. But I do think we are going to run into issues with the other payers for sure too. Because if you call they are still trying to say the same issue.
Yes! We use Insync. We also sent test claims out and they are approved and being processed for payment.
Thank you for your reply. I appreciate it.
So doing the modifier 59 for the G-code is fine still?
The G code no longer needs a modifier at all. You can bill the same as before. I think the only exception right now is Minnesota Medicaid.
I don't have KY Medicaid assigned to me at work, but according to the person who does KY the only one that's paying right now is Humana. We're still holding our KY Medicaid claims so I'm going to assume that we're not getting paid on our test claims either.
Has anyone in Palmetto GBA MAC (NC) seen the updated Billing and Coding Article - Urine Drug Testing (A56915). It was revised 11/12/2023 and now includes this...
If a presumptive screen and definitive drug test are billed the same date of service after July 1, 2023 and medical
necessity for definitive testing is met as stated in L34645 then the subsequent service is subject to NCCI edits and an
appropriate NCCI modifier such as XE or XU should be added to the subsequent drug testing code billed.
This isn't reflected in the Q4 NCCI edits file. I'm torn between XE or XU and do we go ahead and use this for all payers that follow Medicare guidelines.
Open to comments!
No problem! I religiously keep on top of this stuff (my coworkers thing I'm nuts
).