Wiki Humana Denial for Missing Hernia Modifier {Redacted Op Provided}

[RaveenaS]

Humana has sent a letter explaining the claim is denied for missing a required modifier to the primary procedure code. I've reviewed this so many times myself, with my coding team, and I've contacted Humana but the rep state they cannot provide any coding recommendation as they are not part of the coding team and they cannot transfer me to a person who could be of further assistant. So I am hoping the AAPC community can help me out.
I was thinking either a modifier 22 but the provider doesn't state that this extended his case in a significant way, even though it could be assumed it took him some time longer than normal, but he doesn't state that.. So that's my first thought, that maybe they want the 22 for the extensive adhesions he notes but in my experience with other payers, if the provider doesn't say "this extended the case by X% or Xminutes" they usually don't accept the modifier. I thought about 52 because the wound vac was placed, but the wound is noted to be closed, the vac is actually placed on the stapled closure. It's a VENTRAL hernia, mid-abdominal, so no anatomical modifier is relevant. I coded this to CPT49566, ICD K43.0; July 2022.
I'd love to hear your thoughts!
presents with recurrent incarcerated ventral hernia with
obstruction. He was given PCC prior to the operating room. NGT placed and
started on antibiotics.
Findings: 12 cm fascial defect after opening a few Swiss cheese defects superior
to his main hernia defect. 1 area of bowel with some hematoma on it however was
not compromised and no bowel resection was performed. Large volume in
serosanguineous fluid in the hernia sac no purulence. Fascia closed primarily
incisional wound VAC placed over top of stapled incision
Procedure in Detail:
He was brought from ED to OR urgently and after smooth induction of general
anesthesia we placed him supine with arms out. The abdomen was prepped and
draped in sterile fashion. A midline laparotomy incision was made above the
hernia. We bluntly carried this down to the hernia sac and this was dissected
circumferentially. Once this was complete we entered the sac sharply and
identified small bowel. See findings above. An additional hernia defect was
felt superior to her primary hernia defect which was opened up with cautery. I
ran the bowel from the ligament of Treitz to the terminal ileum. I encountered
multiple interloop adhesions which I took down with Metzenbaums. The bowel was
then reduced into the abdomen with additional lysis of adhesions with dense
adhesions to the falciform and midline incision superiorly. This was taken down
with cautery and Metzenbaums. The bowel was then reevaluated and again
confirmed to have no compromise. the hernia sac was resected and identifying
clear fascia. The fascia was then closed with 1Strattafix suture. The wound was
irrigated thoroughly. The subcutaneous tissue was closed with a running 2-0
Vicryl suture and the umbilicus was tacked down to fascia the wound was closed
with staples and a Provena was placed over top.

 

[thomas7331]

Just because they have said a modifier is missing doesn't mean that you've coded the report incorrectly. Have they even requested records or given you an indication that they made the denial based on a coding review? Most likely Humana has denied claim this without having reviewed the report - these kinds of denials are used automated and quite possibly may have nothing at all to do with coding. I certainly do not think that modifier 22 or 52 is the problem. I have heard recently that a payer (perhaps Humana, I can't recall exactly which one) is requesting anatomical modifiers on all hernia codes, which of course is nonsense and is something that they will eventually have to correct when they identify the error, but perhaps that is the situation affecting your particular claim here.

In my opinion, Humana has either made an error or they have implemented a policy that requires certain modifiers on certain codes. In either case, they need to give you a better answer than they have so far. If they've made an error, they need to fix it; or if there is a policy, then they need to show it to you so that you can understand their requirements. I would call them and continue to escalate the call until you speak to someone who will be accountable and can give you a reasonable explanation for the denial - don't let them try to get you off the phone with the 'we can't tell you how to code' excuse that they will always try to use. Alternatively, you can try submitting an appeal with notes and hopefully get a better explanation in writing than you've been given by the phone representatives.