Peg

PedSurgery

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Hello,

We are currently having reimbursement denials from specific carriers using CPT 43246-62.
We perform this procedure with the GI team, we are the Pediatric Surgeons and have previously received reimbursement using the code and modifier listed.

Is anyone else having problems with reimbursement from specific carriers?

Has anything changed regarding billing 43246-62?
We used an example from a Coding Companion book to bill for this procedure.
Thank you for your comments.
 

Lujanwj

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43246 does not allowed for mod -62. If you Dr was called in to place the PEG, you will not need a modifier. If the placement was part of or bundled into the other Dr's procedure, you would use the other Dr's CPT with a -62 or -80, depending on what was done.

You might consider checking the previous reimbursement to make sure you were paid correctly. -62 tells the payer that you are requesting 62.5%(?) back from that procedure rather than 100%.
 

PedSurgery

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Thanks for your reply. We began using 43246 because this is the code that the GI office gave us, and yes we were called in by there office to place the tube part of the procedure. Could you tell me where you found the info that indicates -62 can not be used? We were advised to bill this way from a consultant and from an example in the coding companion workbook. Thanks again for your reply.
 

Lujanwj

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Give us an example of codes that the other Dr is coding. Sounds like there's some confusion. Again, if the PEG was part of or included in another procedure you would use the code that the PEG is part of with the appropriate modifier (-62/-80). If the PEG was done in addition to another procedure that doesn't include a PEG and your Dr did it by him/herself, it's your Dr's work and no modifier needed.

Below is the link to CMS' Physician Fee Schedule. Download the .ZIP file than Open the PPRRVU_122111.xlsx file. That will have all the information.

https://www.cms.gov/Medicare/Medica...FS-Relative-Value-Files-Items/CMS1255291.html
 

PedSurgery

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Thank you for the web links.

The other office is biling for peg code 43246. The GI office does the endoscopic portion of the procedure and we [ped surgeon] place the g tube.
 

kml1764

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Thank you for the web links.

The other office is biling for peg code 43246. The GI office does the endoscopic portion of the procedure and we [ped surgeon] place the g tube.
Okay, so I was looking through the CPT, and when I was looking under -62, it states that when there are 2 surgeons having a distinct purpose in the surgery, BOTH need to have that modifier. If the GI office is not coding with the modifier, then that might be why you are getting denials.
 
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