Wiki Please help!!! Bilateral Xray nightmare

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michellelgrd

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So recently Humana, United, and Peoples Health have been denying our billing of xrays with the RT & LT modifiers, and I cannot get a decent answer as to why. When I call PH they say they denied in error and are sending them for reprocess. Humana says they changed the RT & LT to a 50 modifier but are only paying for one of the xrays. This is happening on ALL the patients, can anyone tell me whats going on? I have searched for days and can't find any information on to why this is just starting to happen.
 
This is what Encoder states:
These are unilateral procedures. If performed bilaterally, some payers require that the service be reported twice with modifier 50 appended to the second code while others require identification of the service only once with modifier 50 appended. Check with individual payers.

So essentially if they are not paying the one line item w/ 50 modifier- bill as two line items w/ 50 modifier on 2nd line item.
73130
73130-50
 
Encoder

We have also received denials for RT/LT saying it's inappropriate on the unilateral xray we billed. We've only rec'd two-one from Anthem and one from Humana. Interestingly, we had appealed the Anthem one and they came back and said they checked Encoder and the denial was correct.
I checked encoderpro to see what modifiers they show appropriate for this unilateral xray and right and left weren't among them, and I couldn't find them on any of the xray codes.
I called Encoder Pro today and spoke with a gentleman there that looked at their update information and they only showed two codes in the radiology section (70 thousand codes) that the RT/LT applied to and they were unilateral breast ultrasound codes.
I also have searched online for some change that took place in radiology that I must have missed, and haven't found anything to explain the denials. I told Encoderpro that I believe this is an error and they seemed to believe it was as well. I was told we wouldn't see the corrections to their system until May 1st due to their corrections process.
We'll see what happens...
 
More info on Humana bilateral xrays/Xrays Rt, Lt

First, I just had an email forwarded to me from an Anthem rep that they recognize the issue with the RT/LT on certain xrays and are working on correcting it. They said the issue should be corrected by May 1st. They also said they will be doing a mass clean up of the denials.

For Humana- I'm being told they want the bilateral xrays billed on one line, with the 50 modifier, 1 unit and Double the price.


Hope this helps,
Terri
 
Frustration with xray billing

I too am suddenly getting denials of xrays performed unilaterally and bilaterally. First it was Humana and now it is Wellcare/Windsor. I have been billing xrays with RT LT for years and have had no problems. What has changed? So far with mine it seems to be just 73562. Everything I read says xrays are not a procedure and are to be paid at 100% for each xray taken. Humana is taking my bilateral xrays with RT LT and bundling them on one line (with the price doubled) and putting a 50 modifier on the code. The only thing is they are paying the same as they did for just one side. I can't find any articles on this stating the rules have changed. It seems to me they are just wanting us to bill them on one line so they can pay only for only one or one and a half. How can we fight this?

Thank you for any help,
Cindy Chalk, CPC
 
Cindy
Our office is having the same problem with Humana only paying for one for our bilateral xrays. Even after doing an appeal they are upholding their original denial. When we started billing the way they asked us to we noticed they were still only paying for one. So it seems we'll be stuck in the appeals process for awhile either way we bill it.
 
I was at a conference this weekend Karen Zupko, and they said, bill what the carriers want, I know for GHI I send with modifiers where Empire I don't, keep a list and do what each carrier wants until its resolved.
 
bilateral xrays

josephmglick said:
Cindy
Our office is having the same problem with Humana only paying for one for our bilateral xrays. Even after doing an appeal they are upholding their original denial. When we started billing the way they asked us to we noticed they were still only paying for one. So it seems we'll be stuck in the appeals process for awhile either way we bill it.
Click to expand...

Thank you for your response. I am so fed up with the insurance companies just changing the rules mid stream whenever and however they want, especially Humana. We had several denials from Wellcare/Windsor also but they were denying everything with an RT or LT modifier. I have been working with the rep there and they say it was a glitch in their system and they are reprocessing all. I wish Humana would come back with that decision.
 
Humana Denial

Has anyone gotten Humana to reprocess a claim with bilateral x-ray correctly? We are fighting them on a bilateral 73562-50 with diagnosis of right knee pain and left knee pain. Humana denies with the xray with "modifier doesn't match the diagnosis"? Any help is appreciated!
 
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