Wiki help with appropriate modifier

[mgarcia400]

I've been struggling with a getting a procedure paid. This was done at a family practice.

DX L02.415- Abscess of lower right extremity

cpt
99213- 25
27301


They've paid office visit but keeps denying 27301 stating "service code inconsistent with reported modifier or required modifier is missing".

What modifier should I add? I've tried 59 and still denied.

Please advise

 

[sls314]

I've been struggling with a getting a procedure paid. This was done at a family practice.

DX L02.415- Abscess of lower right extremity

cpt
99213- 25
27301


They've paid office visit but keeps denying 27301 stating "service code inconsistent with reported modifier or required modifier is missing".

What modifier should I add? I've tried 59 and still denied.

Please advise

Are you sure that 27301 is the correct CPT code?

I suspect they are questioning why that was being billed in the office setting for a family practice. It's on the list of ASC surgical codes.

This is what EncoderPro has for the lay description of 27301:

The physician drains an abscess, a hematoma, or a bursa from deep within the thigh or knee region. The physician makes an incision in the thigh or knee overlying the site of the abscess, hematoma, or bursa to be incised. Dissection is carried through the deep subcutaneous tissues and may be continued into the fascia or muscle to expose the abscess, hematoma, or bursa. The incision may be extended if the mass is larger than expected. When the bursa, abscess, or hematoma is identified, it is incised and the contents are drained. The area is irrigated and the incision is repaired in layers with sutures, staples, and/or Steri-strips; closed with drains in place; or simply left open to further facilitate drainage of infection.

 

[mgarcia400]

Are you sure that 27301 is the correct CPT code?

I suspect they are questioning why that was being billed in the office setting for a family practice. It's on the list of ASC surgical codes.

This is what EncoderPro has for the lay description of 27301:

The physician drains an abscess, a hematoma, or a bursa from deep within the thigh or knee region. The physician makes an incision in the thigh or knee overlying the site of the abscess, hematoma, or bursa to be incised. Dissection is carried through the deep subcutaneous tissues and may be continued into the fascia or muscle to expose the abscess, hematoma, or bursa. The incision may be extended if the mass is larger than expected. When the bursa, abscess, or hematoma is identified, it is incised and the contents are drained. The area is irrigated and the incision is repaired in layers with sutures, staples, and/or Steri-strips; closed with drains in place; or simply left open to further facilitate drainage of infection.

Yes, this is what the physician did for the patient. I'm really having a hard with what modifier they're wanting.

 

[LisaAlonso23]

I've been struggling with a getting a procedure paid. This was done at a family practice.

DX L02.415- Abscess of lower right extremity

cpt
99213- 25
27301


They've paid office visit but keeps denying 27301 stating "service code inconsistent with reported modifier or required modifier is missing".

What modifier should I add? I've tried 59 and still denied.

Please advise

I think that we would need to see the op note to be sure 27301 is the correct CPT code, as this is not usually performed in office and requires anesthesia. 10060 or 10061 may be more appropriate, but it's not possible to know.

 

[sls314]

Yes, this is what the physician did for the patient. I'm really having a hard with what modifier they're wanting.

In the office setting, a family practice physician dissected "through the deep subcutaneous tissues" and perhaps even "continued into the fascia or muscle."

I will take your word for it, since I can't see the documentation and you can. However, that seems highly unlikely to me. That is more extensive than would normally be done in an office setting.

I would encourage you to review the documentation and confirm whether you're truly selecting the correct CPT code.

 

[amyjph]

1. It is highly unlikely to 100% no that a family practice MD did 27301 in office. Orthopedic surgeons take patients to the operating room for this.
2. Even if this really was what was performed, read the global days information on 27301, it is a major surgical procedure.
3. Read the modifier descriptions of 25, 59, 57.
4. Is your role that of a biller or edit fixer, or are you a CPC? You may be looking at this from the wrong viewpoint, the question should be not what modifier but was this coded correctly in the first place (as advised above). I would suggest looking into the 10140, 12020, or 10060.