Denials with 59 modifier

pchamp25

Contributor
Messages
19
Location
New Durham, NH
Best answers
0
We are receiving a lot of denials from different insurance companies when 59 modifier is added to another EGD or Colonoscopy CPT code. Per the guidelines, modifier 59 can be added if a biopsy is obtained in another part of the colonoscopy or esophagus/stomach or obtained using a different technique. I would then submit claims w/45385 and 45380 59 or 43249 and 43239 59 but the claims are coming back w/denials. Am I to use a different modifier when billing for different techniques used during a procedure? We didn't receive claim denials until probably the past couple of months. It seems to be mainly HPHC, Anthem BCBS, and Tufts. Claims are processing correctly through the other insurances, Medicare included. Would modifier 51 be more appropriate?
TIA
 

trarut

True Blue
Messages
673
Location
Columbus, OH
Best answers
0
Have you tried any of the X{EPSU} modifiers instead of the 59? Assuming your payers accept those mods.
Are they denying with a code indicating records are needed? The payer may have an edit in place that will automatically kick out certain combinations and records are needed to support the service.
 

pchamp25

Contributor
Messages
19
Location
New Durham, NH
Best answers
0
Have you tried any of the X{EPSU} modifiers instead of the 59? Assuming your payers accept those mods.
Are they denying with a code indicating records are needed? The payer may have an edit in place that will automatically kick out certain combinations and records are needed to support the service.
Some are denying for medical records but it seems most of them are denying the second code as being inclusive even though a biopsy was obtained from a different site and/or different technique
 

trarut

True Blue
Messages
673
Location
Columbus, OH
Best answers
0
I would try resubmitting a couple of test claims using the XS modifier, indicating a separate site. If they still deny, I'd go the appeals route and supply medical records showing that it was a difference site of service.
 
Top