Wiki Inappropriate Modifier?

[Michael2023]

Hello,

we've been experiencing some denials from a specific insurance (medi-cal contracted) stating inappropriate modifier as the denial reason. What would be appropriate here?

Thank you!

 

[sls314]

Hello,

we've been experiencing some denials from a specific insurance (medi-cal contracted) stating inappropriate modifier as the denial reason. What would be appropriate here?

Thank you!

I'm not sure on the modifier, but I am questioning the diagnosis code used to bill the biopsy.

Uncertain behavior codes should be used only when the pathologist has indicated that the nature of the neoplasm can't be determined as benign or malignant.

Did the documentation support a pathologist's confirmation of an uncertain behavior neoplasm?

 

[jbaird]

Medi-Cal has specific requirements for surgical modifiers. You would need to add AG to the highest RVU surgical CPT and 51 to any additional surgical codes.

https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/4CF63390-6C16-47E5-A11E-5394B01EF278/workbook_surgmod_io.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO

https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/AABC2970-B428-4C76-A86D-0C520B4C50B5/surgbilcms.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO