Wiki Help with Medicare denial please?

[ollielooya]

CLAIM submitted to MCR: This is a claim from 2nd quarter of 2011 before the 173.3 was updated to include 5th digits.
11642 (173.3)
17000-59 (702.0)
17003-59 (702.0.)

Patient also has AARP. MCR paid the 1700X codes but did not pay the 11642 utilizing remark codes CO-B15 and MA18. AARP paid the 17000 codes as well, but didn't touch the 11642.

Since these codes show as being mutually exclusive should I also have attached modifier 59 to the 11642? Is this a case where every single procedure code should be appended with modifier 59 if warranted by the chart notes?

---Suzanne E. Byrum CPC

 

[bjmontana]

Since the 11642 is column two in the mutually exclusive edits, wouldn't that procedure need the 59 mod and the 17000 codes should not need the mod?

 

[ollielooya]

thanks Barb for your reply. While waiting for a response I've been doing some digging and it seems that you could be correct. I'm trying to understand why the 59 should be appended to the 11642 sincee it does have more RVU's and is the higher priced procedure. It's just not sinking in why this would be the correct sequencing/modifier application. Would it not be better to assign modifier 59 to the 17000 series, and yes the add-on code would not need the modifier 59, although I've been receiving some different information regarding that, too. ---Suzanne