Wiki Medicare 59400 with mod 22

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bonnienorth55

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Hello, I have a question for anyone who can help regarding billing a vaginal delivery 59400 to Medicare with modifier 22. We billed it out with mod 22 attached since primary dx is O09.523 for elderly pregnancy and got this SMARTEDIT rejection back: "SMARTEDIT PATTERN 26411 MODIFIER 22 IS NOT APPROPRIATE FOR PROCEDURE CODE 59400 PER MEDICARE GUIDELINES"
I can't find anywhere in their guidelines explaining why we cannot bill a global vaginal delivery with that mod. Any information is greatly appreciated, thank you!
 
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bonnienorth55 said:
Hello, I have a question for anyone who can help regarding billing a vaginal delivery 59400 to Medicare with modifier 22. We billed it out with mod 22 attached since primary dx is O09.523 for elderly pregnancy and got this SMARTEDIT rejection back: "SMARTEDIT PATTERN 26411 MODIFIER 22 IS NOT APPROPRIATE FOR PROCEDURE CODE 59400 PER MEDICARE GUIDELINES"
I can't find anywhere in their guidelines explaining why we cannot bill a global vaginal delivery with that mod. Any information is greatly appreciated, thank you!
Click to expand...

Medicare will only consider Modifier 22 when billed with a procedure that has 0, 10, or 90 global day periods. CPT 59400 does not meet that criteria. (Even if it did, the documentation would have to very clearly demonstrate the specific increased services for the patient. Just the diagnosis code alone wouldn't be sufficient.)

I'm not sure which MAC you bill, but I'm attaching links to the Modifier 22 policies for Novitas, Noridian, CGS, and Palmetto:

 
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sls314 said:
Medicare will only consider Modifier 22 when billed with a procedure that has 0, 10, or 90 global day periods. CPT 59400 does not meet that criteria. (Even if it did, the documentation would have to very clearly demonstrate the specific increased services for the patient. Just the diagnosis code alone wouldn't be sufficient.)

I'm not sure which MAC you bill, but I'm attaching links to the Modifier 22 policies for Novitas, Noridian, CGS, and Palmetto:

Click to expand...
Thank you for this information and the links! When trying to find specific information, I tend to go in circles when searching and can overthink it. This is very helpful and I appreciate it :)
 
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