Wiki Physician's Office IV & home infusion medications and modifiers

[jcfutrell]

We have several patients that require medications to be infused more than once a day therefore after their in office infusion they take home medications from our practice for this purpose. We are running into a recent issue with insurance company's (Humana PPO) not accepting the 76 modifier appended to the medication(s) given in the office and then at home. We bill them on separate claims to identify what was given in the office (11) and what went home (12). We would greatly appreciate any assistance in this matter. Thank you.

 

[thomas7331]

We have several patients that require medications to be infused more than once a day therefore after their in office infusion they take home medications from our practice for this purpose. We are running into a recent issue with insurance company's (Humana PPO) not accepting the 76 modifier appended to the medication(s) given in the office and then at home. We bill them on separate claims to identify what was given in the office (11) and what went home (12). We would greatly appreciate any assistance in this matter. Thank you.

This is kind of an unusual situation you are billing, so you may just need to work with your payers on this and find out how they want these to be billed in order to be correctly paid. But several problems come to mind just looking at this quickly: First, modifier 76 is not correct because that is for a 'repeat procedure', and you are billing for a drug, not a procedure, so this is likely to create an error in the payer's system for that reason alone. You may need to find a different modifier, or combine the drug charges together. Second, the place of service 12 could also be problematic, since you are not actually performing this service in the patient's home. If you are credentialed with the payer as a physician office, then you are probably not set up in the payer's system to provide home care services, so this is also likely causing an error. Third is that if you are dispensing medication for patient home use, essentially acting as a pharmacy so similarly to your not being a home care provider, the payer may not recognize you as a pharmacy provider. Large payers such as Humana usually direct their patients to preferred pharmacies for their drug benefits for cost-savings purposes, so this is quite possibly not a covered benefit that you are providing to the patient, and may not be allowed within your payer contract. So these are just some of the things you will need to consider. You may wish to look into making an arrangement with Humana or their specialty pharmacy to supply these medications for the patient, whereby you can just bill for the administration and physician services and not have to worry about purchasing and billing these and/or potentially losing money. More and more payers are moving in this direction to manage their drug costs. Hope this may help some.

 

[bharathiT]

78 and 79 modifier calrification

03/04/18 -Right eye cataract surgery -66984 -RT (90days global period); global period ends at 06/02/18.
03/18/18 -Left eye cataract surgery -66984 -LT with 79 modifier; global period ends at 06/16/18.
03/20/18 -Removal of retained cortical fragments following left eye cataract surgery -66840 -LT

Which modifier should be used for third procedure on DOS 03/201/18?

Kindly reviewed reply ASAP.