Medicare denial for CPT 99152

chrysel

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Medicare is denying CPT 99152 stating CO 5 which is "procedure code inconsistent with POS" and then M77 which is for either invalid or missing modifier. It was billed as POS 11 and TOS 1. Any suggestions on how this needs to be sent. Any help is appreciated.

Thanks
Chrysel
 
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99152 is a hospital charge. For the POS is 11 (Office) If the charge was done in the office then you need to bill 99202 as Medicare doesn't do consults any more. If it was done in the hospital then it also needs a 21 modifier and bill 99222
 

mitchellde

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99152 is a hospital charge. For the POS is 11 (Office) If the charge was done in the office then you need to bill 99202 as Medicare doesn't do consults any more. If it was done in the hospital then it also needs a 21 modifier and bill 99222

Beth, 99152 is a code that was added 1/1/2017 for moderate sedation. Modifier 21 was deleted in 2009.

I do not know what Medicares issue with 99152 is exactly and from what I understande from others is Medicare does not really understand their issue with it either. If performed in the office setting I can only guess it it relates to the qualified independent observer. Since there is no way to indicate who this person was on the claim you should probably appeal with the documentation. However if your documentation does not clearly identify this person along with their credential within the context of the moderate sedation, then I doubt you will be successful. Somehow they will need to figure this one out.
 

chrysel

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Thanks Beth and Debra for looking into this. Yes, Medicare has not been able to tell me what the issue is. I think appealing is what we will need to do. we do have documentation supporting this.
Chrysel
 
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