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imcbmcc

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I am working on a denied claim for a physician. Initially, the physician performed a 99472 and later in the day also performed sedation for a diagnostic LP.
The billing office billed the services on two claims as such: 1st. claim 99472-25 and 2nd claim 00635. The claim was denied for an NCCI edit; when talking to the insurance representative she said that it might be an incorrect modifier? Would anybody be able to offer an idea of a different modifier to use that can be appended to the 99472?

Thank you so much for any help or advice.
 
Hmmmm.... this just seems like a very odd situation to me. I don't code for anesthesia or pediatrics, but I would imagine it would be unusual for anyone other than an anesthesiologist to administer anesthesia or for an anesthesiologist to provide inpatient critical care.
Regardless, I ran it through a CCI checker and 99472 is a column 2 code for 00635, which means no modifier will override the edit.
Additionally, 99472 description is subsequent inpatient pediatric critical care, PER DAY, for the evaluation & management of a critically ill infant or young child, 29 days - 24 months. Note the PER DAY. So, if the physician provided additional services later in the day, it is still within the same day and not billable separately.

Anyone with experience in either of these areas should feel free to weigh in, but that's my 2 cents.
 
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