Wiki Guidance for newbie needed for 21196 and 21110

[awillis52]

Are services related to the Rt and Lt sides in orthognathic procedures considered separate operatvie areas payable at 100% or should they be bilateral with the 1st paid at 100% and 2nd reduced to 50%. Provider is billing 21196 x2 and 21110 x2.

 

[btadlock1]

Are services related to the Rt and Lt sides in orthognathic procedures considered separate operatvie areas payable at 100% or should they be bilateral with the 1st paid at 100% and 2nd reduced to 50%. Provider is billing 21196 x2 and 21110 x2.

Did they bill with RT or LT modifiers, or a 50 modifier to indicate the procedures are bi-lateral, or did they just bill each twice? If they didn't include location or bi-lateral modifiers, deny the duplicate charges, and pay the more expensive procedure at 100% and the second procedure at 50%, unless your MSP policy instructs otherwise. Many payers have policies based on 'per operative site', but some (like BCBS, for example) pay per operative session or DOS.

If the modifiers are present, follow the same instructions as above, and pay the additional procedures @ 50%. Hope that helps!

 

[awillis52]

Thanks Brandi -1st claim 21196 was billed on 1st line with modifier LT and 21196 was billed on 2nd line with modifier RT, 2nd claim 21110 was billed on 1st line with no modifier and 21110 was billed on 2nd line with 59 modifier

 

[btadlock1]

Thanks Brandi -1st claim 21196 was billed on 1st line with modifier LT and 21196 was billed on 2nd line with modifier RT, 2nd claim 21110 was billed on 1st line with no modifier and 21110 was billed on 2nd line with 59 modifier

Going off of how they billed it, then, I'd process it like this:
21196/LT - pay 100% (or pay 21110 @ 100% and this @ 50% - we don't bill these, so I don't know which one is more expensive - pay 100% on the one with the higher allowable)
21196/RT - pay 50%
21110 - pay (either 50% or 100%, as mentioned above)
21110/59 - deny and request records for review. This should have a location-modifier (LT, RT, or 50). The 59 modifier is for different surgical sites, incisions, lesions or sessions. It's not clear without seeing documentation, why they're reporting the code with a 59 modifier, since it's not necessary to override an NCCI edit. This could very easily be a duplicate charge, or some other circumstance that wouldn't allow them to report the service twice. I know that in our system, we can't just add a modifier to a charge after the fact - we actually have to re-post the whole thing - sometimes, a biller will enter a charge, re-enter it with a modifier that should have been on it, and then forget to delete the original charge, resulting in a duplicate entry. That could have happened here, theoretically, so it's probably better to check before paying, if possible.

Just my 2 cents!