Wiki Modifier 52 or 53?

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MarilynS

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Patient comes in for an infusion of Actemra. Patient starts not to feel good. Doctor ends the infusion before its complete. I billed 96413 and J3262 with mod 53. Humana denied saying modifier is inconsistent with procedure code or required modifier is missing. So I sent a corrected claim adding modifier JZ. Humana denied claim again with same denial verbiage. I'm at a loss. I don't know what they want. Please help. Thanks!!
 
The description of 96413 is "up to one hour of service", so I don't know that you need to report a modifier to indicate that less than 1 hour of the service was performed. There is also a code specific Includes nots that indicates it includes "Includes infusion less than or equal to 15 minutes" per Encoder Pro.
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1) Which procedure codes did you put your modifier(s) on?
2) How long did the infusion last?
I think Actemra can be given for a few different reasons. Was this administered as chemotherapy (96413) or IV infusion for therapy, prophylaxis or diagnosis (96365)?
If the infusion ended early and was not fully administered, I'm not sure why JZ (zero drug amount discarded/not administered to any patient) would be appropriate. It would seem some was discarded if the infusion was not completed.
 
Yes, these are great F/U questions and my first thought was also in regards to modifier placement. I'd really like to see a redacted chart note on this?
 
You would never put a mod 53 on a J code and it sounds like the JZ wasn't appropriate either since there was drug waste as the patient was unable to receive the full dose of the drug.

I agree with what @ollielooya stated above.
ollielooya said:
Yes, these are great F/U questions and my first thought was also in regards to modifier placement. I'd really like to see a redacted chart note on this?
Click to expand...
 
Sounds like your J code should have 2 lines. 1 for amount administered (no modifier), the other for the amount wasted with -JW.
My infusion coding skills are bit rusty, but this is probably a push vs infusion. If official guidance states otherwise, then -53 on the infusion only.
 
Partha45 said:
Modifier 53 is not applicable to use CPT 96413. Please refer link below to verify the modifier eligible for the respective service.

View attachment 6592
Click to expand...
Hmmm, that's odd. Codify is showing that both -52 and -53 are valid modifiers for 96413. Just out of curiosity, I checked a bunch of modifiers on the FSCO link provided and many are coming up as no data was found, but are definitely acceptable modifier/procedure combinations. In fact, I couldn't get any CPT with -53 to show anything other than "no data".
I notice there's an alert at the top of the tool stating there are data issues identified and to use the claims processing manual for additional info.
Regardless, I do think it's a push vs infusion -53, but that should be confirmed.
 
Of course, even if the modifier shows in codify the insurance will not process the claims and deny them. If we verified the FCSO link provided and applied based on those guidelines, the insurance processed the claim without an issue. Also, the CPT 96413 is a time-based code, based on my knowledge to bill this code it requires a minimum of 16 minutes if those criteria are met and the modifier concept is not applied.

Refer to the blog document and it may help you.


 
Last edited:
MarilynS said:
Patient comes in for an infusion of Actemra. Patient starts not to feel good. Doctor ends the infusion before its complete. I billed 96413 and J3262 with mod 53. Humana denied saying modifier is inconsistent with procedure code or required modifier is missing. So I sent a corrected claim adding modifier JZ. Humana denied claim again with same denial verbiage. I'm at a loss. I don't know what they want. Please help. Thanks!!
Click to expand...
Any infusion less than 16m should be coded as a push, 96409. Although, Actemra, to my knowledge isn't billed as chemo. If it was infused for ten minutes you would bill 96734 your initial TPD IV push, <16 minutes. As far as your J code goes, you would have two lines as mentioned above you would use JW and JZ. When I worked for a podiatrist and billed a lot of skin grafts I would have to bill the Q codes for the grafts with JW and JZ to show how many units were used and how many units were discarded, but I am not sure if the guidelines have changed/are the same for the drugs.
 
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