Modifier -53

jrburke

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9
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Kirkland
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We have a physician that did an injection on a patient, patient was scheduled for Right L4/5 L5/S1 Transforaminal ESI, consent was signed, procedure began, under fluro injection could not be completed due to osseous obstruction at both levels, needles were withdrawn, patient was re-anesthetized, and a Right L4/5 Interlaminer ESI was attempted, but again aborted due osseous obstruction; needles were withdrawn, patient was again re-anesthetized,a Right L5/S1 Interlaminer ESI was then attempted but again aborted due osseous obstruction; needles were withdrawn, Since this was the 3rd attempt after discussion with patient decision was made to attempt a Caudal ESI this was successfully completed.

Our thoughts were to bill 64483/53RT, 64484/53RT and 62311. Please let me know if you would agree or if you would just bill for the 62311.

Thank you so much for your professional opinion's on this matter.
 

ljones88

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Stuart, Florida
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This goes back to "What's it worth?"

Keep in mind:
1. Most carriers have specific payment policies regarding 53 modifier. It may help to research the patient's insurance company's payment policy.
2. Some carriers will be reimburse for one discontinued procedure with modifier 53. Additional discontinued procedures for the same date of service may not be eligible for reimbursement.
3. For Medicare patients, double check your MAC. Florida's MAC states"this modifier is used only with colonoscopy through stoma CPT® code 44388, colonoscopy CPT code 45378 and screening colonoscopy codes G0105 and G0121. Any other codes billed with modifier 53 are subject to carrier medical review and priced by individual consideration."
4. Claims submitted with modifier 53 may fall into an edit and request medical documentation to support.
5. NCCI bundles 64483 and 62311 so be sure the appropriate modifier is also attached to 64483.


In this case you have to ask yourself what is the work involved going to cost my doctor to get these codes paid and how much is the code worth with the 53 modifier attached?


Since 64483 is subject to multiple procedure discount AND some payers reduce payment on codes with 53 modifier as well, you have to consider how much it's worth at the end of the day to submit all 3 codes and then fight to get those codes paid. Off the top of my head, in Florida, Coventry/Aetna, UHC, and Humana allow between 20%-60% of the allowable on codes with 53 modifier attached. Factor in the multiple procedure discount on 64483, then you're looking at 20-60% of the 50% allowable on that code.

Showing the math (I'm using our Humana contracted rates, and Humana allows 29% of the allowable when modifier 53 has been attached):
62311: $303.82 allowed in the office
64483/53: $301.79 allowed in the office at 100%. After 50% multiple proc and modifier discount is applied, the new allowable is roughly $107.14
64484/53: $121.23 at 100%. After 50% multiple proc and modifier discount is applied, the new allowable is roughly $43.04

So assuming Humana would eventually pay the claim 100%, the allowable on the claim would be $454.00, in this case.

Now if the dr has one dedicated A/R staff member handling this claim from start to finish, factor in the time and hourly wage it would cost the dr's A/R staff to fight for this, and factor in the time to compile the reconsideration (strong cover letter, printed EOB, medical notes printed, and mailed). Appeals/Reconsiderations can take anywhere between 45-60 days (on a good day) to 90-120 days. A/R will be following up monthly (or so), which is a phone call with hold time, plus talk time...all of this factors into that bottom line; getting those last 2 codes paid.

If the time it takes to appeal for payment on those 2 codes exceeds the payment the dr will eventually receive, it may not be worth the drs time and resources to file the claim with those extra codes. Or file it, and adjust off the codes that get denied; at least it goes on record that the services were rendered, just not reimbursed.

Something to consider. Obviously, if the contracted rates are lower or higher, and the A/R staff's hourly wage is low ($12/hour) or high ($22/hour), all of that will factor into the drs decision to bill the codes out.
 
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