Modifiers 22, 51, 59, 76, and XS for Large Skin Subs

[youngva462@gmail.com]

I know this is a long post, but I see a lot of posts on here where responders as for more information - so, I'm trying to avoid that.

I've broken it into sections in case you want to skin around Section I = Problems (my question basically); II = Situation (the context for my question); III = Proposed coding (how I currently think the encounter should be coded); and IV = Reasoning (why I chose the coding structure)

I. Problems:
(a) Deciding between modifiers -22, -51, -59, -76, and -XS.
(b) MUEs calculation method and assigned number.

II. Situation:
For one patient, during one encounter, at a wound clinic in Florida, we applied 128 units of Q4262 (a skin sub) without waste to one region (left lower leg) with a wound area of 130 sq cm (15273 = 1 unit, 15274 = 1 unit), which is greater than the # of MUEs (however, Ive yet to find what the actual MUE is, but I'm using 10). On the right lower leg (separate region) a selective debridement of 92. 07 sq cm was performed (97597 = 1 unit, 97598 = 4 units). For both regions, a total of 16 units (1 tube) of Omeza (A2014) was applied. The payer (Medicare/MAC = First Coast) has a limit on how much the total charge can be on a single claim ($99,999). We bill on a CMS-1500 claim form.

Our charges work out to the following:
Q4262 @ $1,750 per unit * 128 units = charge of $224,000
15273 @ $1,120 per unit * 1 unit = $1,120
15274 @ $695 per unit * 1 unit = $695
A2014 @ $150 per unit * 16 units = $2,400
97597 @ $205 per unit * 1 unit = $205
97598 @ $90 per unit * 4 units = $360
Total charges for the one encounter = $228,780

Total charges / Charge limit per claim = $228,780 / $90,000 = 2.5 = 3 claims

III. Proposed Coding:
Here is how I think the encounter should be coded, including modifiers, units, order, and claim notes -
/Claim A:
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 6 units = $10,500
Total charges on claim = $98,000
Total units of Q4262 = 56
> Note = "Claim 1 of 3. Separate claim. Not a duplicate."

/Claim B:
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 6 units = $10,500
Total charges on claim = $98,000
Total units of Q4262 = 56
> Note = "Claim 2 of 3. Separate claim. Not a duplicate."

/Claim C:
> Q4262-JZ @ 10 units = $17,500
> Q4262-JZ @ 6 units = $10,500
> 15273 @ 1 unit = $1,120
> 15274 @ 1 unit = $695
> A2014 @ 16 units = $2,400
> 97597-99-51-XS @ 1 unit = $205
> 97598 @ 4 units = $360
Total charges on claim = $32,780
Total units of Q4262 = 16
> Note = "Claim 3 of 3. Separate claim. Not a duplicate."

IV. Reasoning:
> Modifier -JZ because there was no waste of Q4262.
> Modifier -99 because the line has multiple other modifiers.
> Modifier -51 because the procedure (a selective debridement) is usually not paid when a skin sub is performed.
> Modifier -XS to indicate why the -51 modifier is applicable (XS = separate structure).
> It is my understanding that some MUEs are calculated based on 'units per line item' instead of 'units per date of service'. However, I dont know which method is used for skin sub products. So, I'm basing my coding on the 'units per line item' method (wishful thinking at its best).
> CPTS 15274 and 97598 are add-on codes so definitely don't need modifier -51. *But maybe CPT 97598 needs the -XS modifier since the principle code has it?
> I thought modifier -59 could be used to override MUEs, but I'm not sure it would apply if the MUEs are calculated via the 'units per line method'.

 

[Delissad]

I've been working with a reimbursement rep with a graft company and she suggested not to bill the same amount of units and to get the first claim as close to $99,999 as you can. Also you have to put the 15273/4 code with the Q code on each claim. She suggested to make the amount 0.00 or .01 and add a 76 modifier to alert that this is NOT a duplicate claim. She said nothing about 99, 51, or XS and she reviewed my first claim before it went out. Hope this helps!

 

[Delissad]

And yes, JZ for no product wasted or JW if product wasted.