modifier assistance needed payor specific

kim cpc

Contributor
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Buckley, WA
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I'm needing assistance in regards to a denial received for a 43248 and a 43239,2 51. UHC is stating that the 43248 is an integral part because of it being in the same family, they state their following cms guidelines and were billing with the wrong modifier, they also state 59 is not the proper one either so Im curious to see how to properly code this for reimbursement, our medicare patients clms are being paid each separately using the 51. Any help would be greatly appreciated.
Scenario:
No gross lesions noted in entire esophagus. Bx were taken with cold forceps. a guidewire was placed and scope was withdrawn. A 45 Fr. Savary dilator was passed over the guidewire. Dilation was performed for subtle strictures that were not evident on endoscopic exam.

The Z-line was found 39cm from the incisors. BX were taken for histology.

Localized erythematous mucosa with no bleeding was found in the cardia. BX wer taken with cold forceps.

PATH:
GASTRIC BX;
minimal chronic gastritis

DISTAL ESOPHAGUS BX
squamo-cardiac junction mucosa with chronic inflammation
negative for Barretts

ESOPHAGUS, MID, BX
stratisfied squamous epithelium with mild reactive changes

How would you code this out for proper reimbursement any help will be greatly appreciated.
 

elenax

Expert
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Stuart
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I would Code:
43248
43239-59 (Even though the biopsy was done in two separate location it was done only with one method "cold forceps" and this codes allow "single" and "multiple" biopsies)

The following information I got from the "Gastroenterology Coding Alert VOL. 10 2008:

"The modifiers you attach on this claim will depend on your payer. Many coders would likely have to attach modifier 59 to 43239. But some commercial payers in some state, you may have to attach modifier 59 and modifier 51 to get this combinantion paid. Always verify with the CCI. Some payers will want you to use a combo of modifiers"

You said you already got denied, CCI does not bundle 43248 and 43239; I would appeal it with copy of the report and copy of the CCI.

Hope this helps,
 
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