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Denials on 84153 when w/36415

kathleeng

Networker
Messages
59
Location
Fresno, CA
Best answers
0
Is anyone having difficulty on billing 36415 and 84153 together? Lately, I have been getting a denial for 84153 from Blue Shield when billed with 36415. Health plan states to use modifier 59 on this, but I don't feel that is appropriate use of this modifier. I work for an Oncology/Hematology office and we have our own lab. I have came across some information that state that 36415 is not reimbursable by some insurances when billed with the lab codes, but I'm just curious if anyone has any additional information on this. I would be forever grateful!
 

karamac

Networker
Messages
66
Location
Glendale, Arizona
Best answers
0
Some payers bundle the 36415 as part of the laboratory procedure, Moda is one off the top of my head. If you put the 59 modifier, and there is a policy in place at the payer to bundle you are just using that modifier to bypass the edit/policy in place - so I agree don't use it. The 59 modifier, in lab is something that makes my spidey sense alert, especially when I am auditing. It's not that it isn't appropriate in some scenarios, but it is still over used. Have you called the Blue?
 

kathleeng

Networker
Messages
59
Location
Fresno, CA
Best answers
0
Some payers bundle the 36415 as part of the laboratory procedure, Moda is one off the top of my head. If you put the 59 modifier, and there is a policy in place at the payer to bundle you are just using that modifier to bypass the edit/policy in place - so I agree don't use it. The 59 modifier, in lab is something that makes my spidey sense alert, especially when I am auditing. It's not that it isn't appropriate in some scenarios, but it is still over used. Have you called the Blue?
Hi Kara, thank you for your response. I have not, but several members of our AR team have and they all get the same response. 84153 is bundling with 36415, according to the health plans. We have tried appealing it to get payment for 84153 and the appeal was also denied. We have a covered diagnosis according to the LCD. I recently found on Medicare that when billing 84153, you cannot bill 36415 so I'm hoping if we bill without the venipuncture that will correct the issue going forward.
 
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