Wiki Interventional Cardiology Help!

[davidbang]

Hello, I have started to work at for a private cardiology clinic that also does interventional cardiology. I have self-taught this specific field so that I can be ready for it, and unfortunately I was thrown in without any mentors or the training of the previous coder/biller. I had a question about a denial for incorrect use of modifier.

The CPT codes are 76937-26, 92928-59-LC-26, 93458-26 for the same DOS. 92928 was denied but the others were paid.

I am having a hard time understanding why it was denied when other insurance companies have paid for similar coding of -59 on the stent. And how can I go about appealing this?

Thank you in advance!

EDIT: It seems that the same insurance company (health net of CA) also denied 92928 when -59 was appended to 93458 instead for another patient. I am clueless about what to do!

 

[xXxPARAGONxXx]

When we input 76937 into CMS Physician Fee Schedule, it clearly shows that the service has both a professional a technical component, as indicated by modifier -26 and -TC, respectively.

https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=4&HT=0&CT=0&H1=76937&M=5



However, when we input 92928, there is no indication that the service has a professional and a technical component. Therefore, one should not use either modifier, -26 or -TC, when submitting claims for 92928.

https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=4&HT=0&CT=0&H1=92928&M=5



Finally, when we input 93458 in CMS Physician Fee Schedule, it does show a professional and a technical component.

https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=4&HT=0&CT=0&H1=93458M=5



You coded:

76937-26, 92928-59-LC-26, 93458-26 for the same DOS. [92928 was denied but the others were paid.]

Also, ranking the three CPT codes according to RVU, they should be ranked from highest to lowest as follows:

1. 92928 (10.96)
2. 93458 (5.60)
3. 76937 (0.30)

Per NCCI edit spreadsheet, modifier -59 should be appended to 93458, as it is the column 2 code with indicator 1, and 92928 is the column 1 code.



76937 is not found associated with 92928 or 93458 on the NCCI edit spreadsheet, which means you do not need to use modifier -59 with it as its service does not overlap the other two.

So, submit a claim for: 92928-LC, 93458-59-26, 76937-26.

Neither modifier -26 nor modifier -59 should be appended to 92928.