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

 

[amcook31]

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?

We are taught this as coders but I have not been able to find it in our guidelines. If you know where it is can you share a page number? The AAD (American Academy of Dermatology) instructs their providers to use this code for questionable lesions. We report this on a good portion of our biopsies and pathology and have no issues. I still feel like it's wrong, but my organization sided with the providers when we couldn't produce a guideline.

 

[LisaAlonso23]

Page 513 has a note that states uncertain behavior codes should be used when histological confirmation of benign or malignant of a neoplasm cannot be determined.

Uncertain histological behavior can only be determined by a pathologist, therefore unspecified neoplasm codes should be used when the type of neoplasm is unknown.