Wiki CPT 28485 proper way to bill multiple units

[Heatherc7]

Hello,

I could really use some advice on the proper way to bill multiple units of CPT 28485-LT.

I billed:
28485-LT
28485-XS-76- LT
28485-XS-76-LT
Outcome: Medicaid paid the first two lines and denied the 3rd as a duplicate.

Would it be appropriate to bill CPT 28485-LT, 28485-XS-76-LT (2 units)?

Thank you in advance for your help!

 

[NRaizman]

The MUE is 5 for that code, as, naturally, there are five metatarsals. You should be fine with a -51 modifier.
There is no reason for denial and I would appeal.
N.

 

[amyjph]

Do you have the correct diagnosis attached to each line? Make sure each line only has the single dx code for the MT treated. They might want the toe modifiers even though it is MT and that is not "technically" correct. I have seen where this is the case before. I would not use 76 unless they specifically tell you to. Does the MCD plan you are billing recognize the X mods? If no, you might need a 51 or 59 however, 51 is pretty much obsolete at this point. Sometimes MCD plans have weird rules, have you checked the provider manual and/or fee schedule?

You might try 28485, three lines, one unit, with the corresponding T mod and single correct dx pointer on each line. 2 units on one line probably will make it worse.

 

[Heatherc7]

Do you have the correct diagnosis attached to each line? Make sure each line only has the single dx code for the MT treated. They might want the toe modifiers even though it is MT and that is not "technically" correct. I have seen where this is the case before. I would not use 76 unless they specifically tell you to. Does the MCD plan you are billing recognize the X mods? If no, you might need a 51 or 59 however, 51 is pretty much obsolete at this point. Sometimes MCD plans have weird rules, have you checked the provider manual and/or fee schedule?

You might try 28485, three lines, one unit, with the corresponding T mod and single correct dx pointer on each line. 2 units on one line probably will make it worse.

Hi, thank you for your response. The Dx's are: S92.322A, S92.332A, S92.342A. They paid for CPT 28485-LT and 28485-XS-76-LT. It's the third line CPT 28485-XS-76-LT w/ Dx S92.342A they're denying as a duplicate. Based on the update info, would it make sense to bill CPT 28485-XS-76-LT (2 units) or do you still think it would make it worse? Also, based on the info do you think that modifier -76 is appropriate, with a separate incision & Dx? Unfortunately, the CCO Medicaid manual didn't give any guidance. Thank you again for your help!

 

[Heatherc7]

The MUE is 5 for that code, as, naturally, there are five metatarsals. You should be fine with a -51 modifier.
There is no reason for denial and I would appeal.
N.

Thank you for your response! The Dx's are for separate metatarsals S92.322A, S92.332A, S92.342A, through a separate incision. Do you think modifier -76 is appropriate? I appreciate any guidance!

 

[amyjph]

Did you check their specific fee schedule to see if they allow more than 2 in a operative session?
The third line does look like a duplicate "in writing". Two units is probably not the way to go because the CPT code description says "each".
The T mods might help. Or 59 instead of XS and remove the 76. It's not really a repeat procedure even though the CPT code is reported 3x, it is 3 unique procedures on three separate MTs. I would not suggest 76 here.
Other than that you would probably have to appeal, which stinks.