Wiki Modifier 50 - I have a private carrier

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companey

companey

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I have a private carrier who has denied our claims for a injection code 64612 with modifier 50. When I called and spoke with Claims Supervisor I was read the diffention and because it says muscle(s). She says we can not use modifier 50. CMS pays and other private payors. Can Someone please help me with this?
Thank you,
Jessica Companey, CPC
 
That is correct. In the description of the cpt code it states "muscle(s)" this idicates one or more are included in the procedure otherwise it would state "each" or there would be an add on code that stated "each additional"
 
There certainly seems to be a discrepency here...

Medicare does have a bilateral payment indicator of 1...which would allow modifier 50; however, CPT Assistant clearly indicates, in a few articles, that 64612 is reported once, even though more than one injection may be required to complete the procedure.
 
This was bugging me so I dug a little deeper...

Can the codes be billed bilaterally?

Chemodenervation codes 64612, 64613, and 64614 are identified in the MPFS database as codes for which the allowance for procedures performed bilaterally will be 150% of allowance for the unilateral service. Bilateral procedures may be reported on a single line using modifier -50 and reporting 1 unit of service. Alternatively, bilateral procedures may be reported on 2 lines using the RT and LT modifiers and reporting 1 unit of service for each. Please note, under the MPFS, Medicare payment is set as the lesser of the fee schedule allowance or the actual charge.

Anecdotally, there are a variety of differing policies from other payers. Therefore, we now inform our members that there is variability in the policies different insurance carriers and health plans have regarding these codes. The individual provider will need to determine what is the proper billing procedure for these codes in his or her locality for the specific payer to whom a claim is submitted.

http://www.aan.com/news/?event=read&article_id=4746

One Medicare carrier has an exception to the rule...

CPT codes 64612-64614 should be reported only one (1) time per procedure, even if multiple injections are performed in sites along a single muscle or if several muscles in a functional muscle group are injected.

However, in the case of treating bilateral blepharospasm, procedure code 64612 may be billed once for each eye with the appropriate modifier. In this case procedure code 64612 is allowed at 150% when performed bilaterally

So this will become carrier discretion. I would check with your carriers and get their policy in writing...
 
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