Wiki Moderate Sedation with Colonoscopy

[taurus7694]

We received a denial from United Healthcare for 99152. Their Claim/Coding Logic says: Not supported. This code is included in CPT code 43239,45380; therefore, it cannot be separately reimbursed.

We billed 99152 with a 59 modifier.

Does anyone know if UHC prefers G0500 instead of 99152? Also, is anyone using XU modifier and seeing reimbursement for 99152?

In reference to :
Effective January 1, 2017, the Centers for Medicare and Medicaid Services is separating moderate sedation services from hundreds of procedure codes, including the majority of GI endoscopy procedures under Medicare Part B.

Can anyone tell me why colonoscopy and moderate sedation still hit for an NCCI edit? What justification do we have to override that edit with modifier 59?

Thank you!

 

[jkyles]

Hi there, you'll need to check the specific plan to see whether you should report the CPT or HCPCS code. But what was the rationale for reporting moderate sedation as a distinct service? Here's the full descriptor for modifier 59, emphasis added:

Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.