Wiki Modifier 59 causing claim to deny?

sinman0531

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I have always thought that if a modifier -59 got added onto a claim accidentally that it wouldn't affect payment. I personally have been looking at claims for over seven years and have never seen a payer deny a line simply because there was a modifier -59 attached. However we are receiving a denial from Optimum stating that because we have a -59 modifier on a line when it shouldn't be there (but in reality it should), they're not paying *any* lines, and this is an almost six thousand dollar claim.
 
What are the codes/claim for? There could be a lot of answers to this. There are codes a 59 should not be appended to, there are times when an X or anatomical modifier is more appropriate.

This is what/how it was billed:

17311
17312
13131
11604-59
11604-59-76
12034
13121

They are claiming the first 11604 should not have the -modifer 59 attached (this is per two different reps) the denials are "procedure modifier was invalid on the DOS".
 
This is what/how it was billed:

17311
17312
13131
11604-59
11604-59-76
12034
13121

They are claiming the first 11604 should not have the -modifer 59 attached (this is per two different reps) the denials are "procedure modifier was invalid on the DOS".
I think you are being given incorrect information - the modifier is necessary on both instances of 11604 in order to unbundle those codes from the Mohs procedure.

I would recommend removing modifier 76 - it is not necessary in addition to the 59 modifier and some payers do not allow that modifier with surgical codes (and in my view is incorrect since this is not a repeated procedure - it's a different procedure at a different site that happens to be reported with the same code).

As mentioned in the post above, I would also replace the modifiers 59 with XS instead, as that is more specific, although 59 should not be causing a denial.
 
I have a question on inpatient and modifiers specifically when the insurance is Medicaid/Medicare. When this is inpatient no modifiers are added because the office visit captures everything is this correct. For example POC through out the day and more than one day, I was added XU. If it’s a pathology different anatomical sites then I was adding XS but am now informed inpatient uses no modifiers I am very confused can someone help clarify inpatient with Medicaid and Medicare insurance do they not use modifiers coding inpatient encounters

Thank you in advance
 
I am seeing more and more payors wanted the XS or XU modifier rather than the 59 modifier. For what reason, I'm not sure. But yes, this is becoming more and more common.
 
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