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Medicare Denial: MA130-CLM IS UNPROCSSBLE, SBMT NEW CLM/

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Medicare Denial: MA130-CLM IS UNPROCSSBLE, SBMT NEW CLM and 4-PX INCONS W/ MODIF/REQD MODIF MISSNG

CPT/Modifiers
19370 Modifiers 78,50,XU
19328 Modifiers 78,50,XU
19342 Modifiers 78,50
Dx: C50.111
Patient was brought into the room and placed in the supine position. General anesthesia was administered. The patient's chest was prepped and draped in a sterile fashion. An incision on the right side was made through the lower incision of the latissimus flap. On the left side was made through the mastectomy scar. Dissection was carried down through the soft tissue and muscle to the breast capsule. The capsule was incised. The tissue expander was deflated and removed intact. An extensive capsulotomy was then performed around the base of the implant pocket and then up radial to the incision. Sizers were placed and was determined that a 550 cc style 45 high profile implant was to be used on the right and a 539 cc ultra high implant was to be used on the left. The pockets were irrigated with saline solution there was good hemostasis. The pockets were then instilled with a Betadine-saline mixture. My gloves were changed, and has only 1 to handle the implant. A Keller funnel was used to place both the implants. The implants were placed without difficulty. The breast capsule, muscle, and soft tissue were reapproximated over the implant using 3-0 Monocryl suture. The skin was closed using 3-0 Monocryl deep dermal sutures and 4-0 Monocryl running subcuticular. I did have to take a little extra skin out on the right side to tighten up over the implant to try to match the size of the left side. Patient tolerated the procedure well and was transferred to recovery room in stable condition

I've tried a number of modifier combinations & Medicare has rejected all.
Thank you for any insight
 

thomas7331

True Blue
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I'm not strong in this specialty, but it appears to me you're billing a bilateral primary procedure and then using an XU modifier to indicate a separate procedure, but then the XU modifier can't be supported in this situation - if the primary procedure is being done on both sides, there is no third location to warrant an additional procedure with a modifier. Just looking briefly at the report, I don't think that this procedure is coded correctly - as I understand it, 19328 is for removal of a prosthesis, not for removal of the tissue expanders, which is inclusive to 19342. In addition, the bilateral capsulotomy 19370-50 is a component of 19342-50 so the modifier is not warranted here. I suspect this entire procedure should be coded just as 19342-50, but perhaps someone here with more experience in these can give you some additional input.
 

coop22

Networker
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I would look into Modifier XS or 59. And don't forget 51 for multiple procedures.
 

mitchellde

True Blue
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Columbia, MO
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From the note provided I am not seeing the documentation to support all of the codes you have billed out . How long after the Mastectomy was this performed? was the mastectomy only on the left side or was it bilateral? why did you use the XU modifier, what was unusual in this procedure? What I see in the documentation is the insertion of breast implants after a mastectomy. there does not appear to be anything more. So was this delayed after the global or was it immediate after the mastectomy, or were there two separate mastectomys at two different times? You need to match the procedure to a code that explains what was really done and use modifiers to help clarify when the code needs assistance. from this note I see one procedure performed bilateral.
 
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