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Modifier 57 triggered audit

Barrister

New
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2
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0
We used modifier 57 along with E/M 99222. CMS denied payment. We appealed their audit by providing documents showing emergency findings which led to a procedure the next day. We also referenced CMS Publication 100-04; Chapter 12 in Section 40.1(B) “Services Not Included in the Global Surgical Packages…. may be paid for separately.” CMS still denied. Please provide suggestions? tips ? Thank you Kate
 

thomas7331

True Blue
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2,052
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If they have not explained their reasoning for the denial and you still disagree, I would take the appeal to the next level. In my experience, Medicare contractors will often deny a first appeal without explaining their rationale for doing so. Submitting a second level appeal, which will involve a more thorough review of your documentation, will get you a response that usually includes a detailed explanation of why they are upholding the denial, and will also give you a better indication of what their expectations are, which will in turn be helpful for reference in future denials and may also provide an opportunity for documentation and/or coding improvement.
 
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