Wiki Modifier

[CGUNN]

Hello. I work for a pediatric surgeon and we are trying to bill CPT 13101 & 13102 and it is denying for modifier. What modifier should I be using? Any help would be great, thank you!

 

[trarut]

Is the payer denying or are the charges failing claim edits in your billing system? 13102 is an add-on code and technically should not require a modifier so my advice differs based on that answer.

• If the denial is due to a claim edit in your billing system and you are confident the coding is correct, there should be a process to override the edit and force the claim to bill (in our PM system, it's called creating a "dirty" claim).
• If the payer is denying, do they have a policy for that describes how they want these submitted? If you can't find one, call them and ask what policy they're applying to deny the charge(s). Some payers publish their claim edits instead of a policy. The policy could be a clinical or reimbursement policy.

I would be reluctant to use a 59 modifier without investigating further but if you do, I would include something in the narrative field to justify or explain the use of the add-on code.

Hope this helps.