Wiki Occupational therapy partial denial on multiple codes

[kquinby]

I am new to billing occupational therapy codes and received a partial denial for the 2nd and 3rd codes for 1 visit. Denial on claim is as follows: 59 - Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.

I am billing 97110, 97530, and 97535 with a GO modifier. The adjusted reimbursement is about 25% less than the agreed rate.

Is there anyway to get full payment? Should I be using modifier 59?

 

[lefevrec]

Their EOB states the payments for the other procedures have been decreased because multiple procedures were done. This decrease is because payment accounts for many different costs involved in the care; part of which is the facility overhead. Since this was all done at one visit, they pay the primary procedure in full and decrease the rest accordingly. This is common practice with many payers and different types of services. I believe you were paid appropriately, based on their contractual adjustment.

 

[reserashley]

Their EOB states the payments for the other procedures have been decreased because multiple procedures were done. This decrease is because payment accounts for many different costs involved in the care; part of which is the facility overhead. Since this was all done at one visit, they pay the primary procedure in full and decrease the rest accordingly. This is common practice with many payers and different types of services. I believe you were paid appropriately, based on their contractual adjustment.

With 97530 and 97535, you should always use a -59 modifier on 97535 and you should get full reimbursement, depending on the payer.

 

[kquinby]

Thank you both so much for your input. I've sent corrected claims with 59 so we will see what happens!