Wiki CPT 64483 What is the issue with modifier?

schanderson

Networker
Local Chapter Officer
Messages
27
Best answers
0
I am stumped since the CMS updated the LCD L39054 and my doctor has performed a few of these claims that are getting denied for a modifier. It has the modifier RT for the right side what else am I supposed to do the claim to get them paid because it has a modifier and I cannot get them paid. The only thing I see is that the patients are diabetic so we test them for the sugar, but I am just stumped. The books I read says that the modifier is allowed and all fo them point to the the L39054 as to why they are denying the claim.
 
It is 64483 RT the diagnosis is valid per the CMS there is one line and one unit on the right side
 
I am stumped since the CMS updated the LCD L39054 and my doctor has performed a few of these claims that are getting denied for a modifier. It has the modifier RT for the right side what else am I supposed to do the claim to get them paid because it has a modifier and I cannot get them paid. The only thing I see is that the patients are diabetic so we test them for the sugar, but I am just stumped. The books I read says that the modifier is allowed and all fo them point to the the L39054 as to why they are denying the claim.
 
we are also seeing denials on this as well. billed 64483-tr and 64484-rt,, and denied for missing modifier. I believe it has something to do with the verbiage on the new LCD regarding KX modifier. Our documentation clearly states a TFESI was done, not a DNSRB,so KX is not appropriate on TFESI, however our claim has denied and appeal also denied.

the current lcd policy states"
KX Modifier Requirements

A diagnostic selective nerve root block (DSNRB) is identically coded as an epidural injection. Therefore, when performing a DSNRB, the -KX modifier should be appended to the appropriate line to distinguish the procedure from an epidural injection. This applies to TFESI CPT codes 64479, 64480, 64483, and 64484. Aberrant use of the -KX modifier may trigger focused medical review.
 
can i ask what payer everyone is having this issue with ? only Medicare or Medicare advantage plans. We are having it with AARP UHC Medicare Advantage plans
 
Yes, if it's only one payer such as UHC MCR Advantage and not straight MCR I would check to see if there have been any notifications of errors on their side. If it's only one specific payer they could have some random guideline or rule no one else does possibly. There are plenty of times the payer has issues on their side. Also, your claims are making it through the clearinghouse, not rejecting and coming back as a denial on EOB?
 
Yes, if it's only one payer such as UHC MCR Advantage and not straight MCR I would check to see if there have been any notifications of errors on their side. If it's only one specific payer they could have some random guideline or rule no one else does possibly. There are plenty of times the payer has issues on their side. Also, your claims are making it through the clearinghouse, not rejecting and coming back as a denial on EOB?
yes, they are making it through the clearinghouse, and we are receiving eob denials for missing modifier. We have the RT modifier on 64483/64484. we even called UHC Medciare on these and the rep confirmed the eob denial for missing modifier is correct. Since UHC Medicare follow Medicare medical policy, they are stating missing modifier. Actually sent appeal to UHC medicare on one case, because the KX modifier was not appropriate according to the new LCD , we performed TFESI,not DSNRB. the appeal has also denied.
From what i am reading in the CMS policy it states:
"A diagnostic selective nerve root block (DSNRB) is identically coded as an epidural injection. Therefore, when performing a DSNRB, the -KX modifier should be appended to the appropriate line to distinguish the procedure from an epidural injection. This applies to TFESI CPT codes 64479, 64480, 64483, and 64484. Aberrant use of the -KX modifier may trigger focused medical review."
 
yes, they are making it through the clearinghouse, and we are receiving eob denials for missing modifier. We have the RT modifier on 64483/64484. we even called UHC Medciare on these and the rep confirmed the eob denial for missing modifier is correct. Since UHC Medicare follow Medicare medical policy, they are stating missing modifier. Actually sent appeal to UHC medicare on one case, because the KX modifier was not appropriate according to the new LCD , we performed TFESI,not DSNRB. the appeal has also denied.
From what i am reading in the CMS policy it states:
"A diagnostic selective nerve root block (DSNRB) is identically coded as an epidural injection. Therefore, when performing a DSNRB, the -KX modifier should be appended to the appropriate line to distinguish the procedure from an epidural injection. This applies to TFESI CPT codes 64479, 64480, 64483, and 64484. Aberrant use of the -KX modifier may trigger focused medical review."
Frustrating. Sounds like their edits or reason codes are broken. Is it every time you bill 64483 to all UHC MCR? Wondering if it's something else like the dx code, MUE, etc and it's coming back w/ the wrong reason code for denial. I don't really trust anything those reps say, they are just reading back what's on the EOB. Do you have a provider rep you can go to?
 
Top