Wiki Denial CO-59

[Leann0523]

Denial for an office visit with a shave biopsy and destruction. Have the modifier on the 99213-25 and the modifier on the 11102-59 and ins denied the office visit with CO-59 Processed based on multiple or concurrent procedure rules. Refer to the 835 Healthcare Policy Identification segment (loop 2110 service payment info) pt has BCBS Medicare Advantage . Please help

 

[kdlberg]

If it was decided, after exam and assessment, to do the biopsy/destruction, the documentation should back this up and you can use that to resubmit. It needs to demonstrate that A to B to C thinking process.

If the patient came in for the biopsy, you can't bill 99213, because the related E/M services are included in the biopsy code.

My question is why is there a modifier -59? "Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances." There's not a second procedure here. Or did you also bill the 17000 for the destruction? This combination (11102 with 17000) is specifically addressed in the MLN Fact sheet: https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf

 

[aimeec87]

You must also make sure that the provider states that the E/M service was separately identifiable from the procedure provided. <<<<< That is KEY!

 

[TatyanaP]

CARC denial CO-59 with RARC N362 - The number of days or Units of Services exceeds acceptable maximum. The system reads modifier 59 as number of units.

 

[lscullin]

System auto applied Insurance adjustment for CO-45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Adjustment applied by ERA application.*
For PT and MT. It is not just Medicare giving this code, it is also Aetna and Premera. How can I fix this? It is not normal.

 

[SDargaj]

System auto applied Insurance adjustment for CO-45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Adjustment applied by ERA application.*
For PT and MT. It is not just Medicare giving this code, it is also Aetna and Premera. How can I fix this? It is not normal.

This is normal........all insurances have an allowable amount for different services. This CO-45 adj is basically whatever amount is left after payment/other adj's have been made. It's not payable as it is what is left over after the allowable has been met

 

[lscullin]

This is normal........all insurances have an allowable amount for different services. This CO-45 adj is basically whatever amount is left after payment/other adj's have been made. It's not payable as it is what is left over after the allowable has been met

System auto applied Insurance adjustment for CO-45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Adjustment applied by ERA application.*
For PT and MT. It is not just Medicare giving this code, it is also Aetna and Premera. How can I fix this? It is not normal.

I ment to say CO-59. Sorry, I have a lot of coding review in my box and I am not sure what to do.

 

[SDargaj]

System auto applied Insurance adjustment for CO-45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Adjustment applied by ERA application.*
For PT and MT. It is not just Medicare giving this code, it is also Aetna and Premera. How can I fix this? It is not normal.

I ment to say CO-59. Sorry, I have a lot of coding review in my box and I am not sure what to do.

Okay, gotcha.......CO-59 is typically associated with "bundling issues", so it's hard to say exactly without specifics of what you are billing

 

[lscullin]

Okay, gotcha.......CO-59 is typically associated with "bundling issues", so it's hard to say exactly without specifics of what you are billing

Right now it is Noridian and Aetna for PT, OT, MT CPT's (MT 97124) (PT all CPT's) (OT all CPT's).