Wiki Denial 92960

[kvogel03]

Hello Everyone,

I have billed out 33235 78, 33216 78, and 92960 59. I have received a denial for 92960 stating it is inclusive. I have been doing some research to figure this out. Is 92960 inclusive to the 33235 and 33216 ? If not what would be the appropriate modifier to use ?

Thanks,

Kayla

 

[trarut]

Did you check the NCCI edits? 92960 has a bundling relationship with 33235. This is from Codify's CCI Checker:

CCI Validation Results:
Code 92960 is a column 2 code for 33235, but you may use a CCI-associated modifier to override the edit under appropriate circumstances.
CCI Edit Rule:
Standards of medical / surgical practice

Code 92960 is a column 2 code for 33216, but you may use a CCI-associated modifier to override the edit under appropriate circumstances.
CCI Edit Rule:
Standards of medical / surgical practice

The current CCI-associated modifiers are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, LM, RC, RI, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, XE, XP, XS, XU, 24, 25, 27, 57, 58, 59, 78, 79, and 91. (View CPT® and HCPCS modifiers.)

 

[kvogel03]

Did you check the NCCI edits? 92960 has a bundling relationship with 33235. This is from Codify's CCI Checker:

CCI Validation Results:
Code 92960 is a column 2 code for 33235, but you may use a CCI-associated modifier to override the edit under appropriate circumstances.
CCI Edit Rule:
Standards of medical / surgical practice

Code 92960 is a column 2 code for 33216, but you may use a CCI-associated modifier to override the edit under appropriate circumstances.
CCI Edit Rule:
Standards of medical / surgical practice

The current CCI-associated modifiers are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, LM, RC, RI, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, XE, XP, XS, XU, 24, 25, 27, 57, 58, 59, 78, 79, and 91. (View CPT® and HCPCS modifiers.)

Yes I did check CCI edits and received the same CCI Edits as you listed below that is why I appended the 59 modifier to 92960. Since I got the denial with the 59 modifier. Just to make sure I am understanding this correctly I cant bill 92960 with 33235.

 

[trarut]

You can bill the two codes together IF they're medically appropriate and you use one of the listed modifiers - which you did.

If the payer is saying it's inclusive after you've submitted with a 59 modifier, they likely have their own bundling policy that they are applying. I would check the payer's website for a medical policy or reimbursement policy that may provide additional guidance. Alternatively, you could appeal and provide medical records to show why it should be paid separately.

 

[kvogel03]

You can bill the two codes together IF they're medically appropriate and you use one of the listed modifiers - which you did.

If the payer is saying it's inclusive after you've submitted with a 59 modifier, they likely have their own bundling policy that they are applying. I would check the payer's website for a medical policy or reimbursement policy that may provide additional guidance. Alternatively, you could appeal and provide medical records to show why it should be paid separately.

Ok. Thanks for you help. I will give that a try.

 

[Misty Dawn]

92960 is for "elective" cardioversion. You can only add modifier 59 if the cardioversion was elective.

Example when a modifier is not allowed: If the provider removed the electrode(s) and this caused an arrhythmia that required cardioversion; the cardioversion would be included in the primary procedure and not separately reportable. (pt did not elect for cardioversion because arrhythmia presented during the electrode removal.)

Example when a modifier is allowed: Pt is scheduled for cardioversion due to arrhythmia and also for removal of the electrode(s).
Example when a modifier is allowed: Pt presents in afib and cardioversion is needed before planned surgery can begin. Pt agrees to proceed with cardioversion.

 

[kvogel03]

92960 is for "elective" cardioversion. You can only add modifier 59 if the cardioversion was elective.

Example when a modifier is not allowed: If the provider removed the electrode(s) and this caused an arrhythmia that required cardioversion; the cardioversion would be included in the primary procedure and not separately reportable. (pt did not elect for cardioversion because arrhythmia presented during the electrode removal.)

Example when a modifier is allowed: Pt is scheduled for cardioversion due to arrhythmia and also for removal of the electrode(s).
Example when a modifier is allowed: Pt presents in afib and cardioversion is needed before planned surgery can begin. Pt agrees to proceed with cardioversion.

Thanks for your information.

 

[christinerw27@gmail.com]

can I piggy back a question about 92960?
if the planned procedure is a PVI, and they DCCV him prior to the start, this can be billed. Does this need to be modified with a '79'?
thanks in advance