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banderson77

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I have a spine specialist in my group and when he does his major surgeries he bills 22851, 20926, 22585 and 22614 multiple times for the various levels. Any recommendations on how we can get these paid? We have tried several different ways and they always get denied. Any help will be helpful.:D
 
mleckrone

Hi .. are you billing these procedure on separate lines? If so I would recommend that you bill the add on codes with units rather then use separate line items. Some payers however, would prefer separate lines, but Medicare will honor the units. If billing separate lines use the modifer 59 for the addional lines.
 
I dont agree with the modifier 51, add on codes are modifier 51 exempt and it would not be appropriate to use 51, you are encouraging the insurance carrier to reduce the add ons by 50%. There shouldnt be any reduction on add on codes. Some carriers want multiple units of add on codes billed with multiple units, some want them billed per line with the 59 modifier added.
 
Put a 59 on add on codes????? Really? I was taught that no modifiers go on add on codes. I think that's what is causing the confusion in my office.:confused:
 
All the codes you gave were not add on codes. IT is the rule, you have to apply a 51 modifier to multiple surgery codes for price reduction, if you don't, then you will be an auditors dream. Also, modifiers can be added to add on codes, such as 22, 52, and others. Definitely not a 51. You shouldn't be using a 59 modifier anyway for surgery. Also,list the highest surgery cost first.
Simone
 
Again, I disagree. You do not add 51 to add on codes, all of the codes listed except 20926 were add on codes and yes you can add a 59 modifier to add on codes if that is what your insurance requires. You will not be audited and if you are as long as what you are billing is properly documented you do not have anything to worry about. At the AANS seminar they will tell you to use a 59 on add on codes in some cases. I just sent a case I needed help on to one of the presenters of the AANS seminar who we contract for coding help. It was a 3 level anterior fusion and disckectomy. She said to bill this as: 22551, 22552, 22552 - 59, 22846 and 20931 OR 22551, 22552 x 2, 22846 and 20931 depending on the insurance companies. They tell you to due this in the seminar as well. Also, I dont understand why it would be suggested to not use a 59 modifier for surgery, you wouldnt use a 59 modifier except for surgery codes.
 
We do use 51 on our codes that are not 51 exempt. We will have to disagree on the modifier issue as I still stand by the coding advice given by presenters at the AANS seminar. Also, we did have a routine audit of our office done by BCBS and nothing had to be paid back, no errors in our coding were found. The best advice I can give to the original question is to check with your carrier about what they find acceptable as far as modifiers go, with all modifiers it may be dependent on the carrier. Just like to certain carriers we would bill 80 AS or 82 AS for the physician assistant at surgery, some carriers we bill units, some we bill per line item with the 59. There is one Medicare carrier, (not ours), that does not want 51 added to any of their codes because it is often used incorrectly. Thanks to the original question, banderson 77, for bringing up this topic!
 
This is what and how we billed the following 3 surgeries:

Patient #1:
22551, 22845, 20926, 20926-59, 22851, 22851-59

Patient #2 1st sx:
22558, 20926, 20926-59, 20926-59, 20926-59, 22851, 22851-59, 22851-59, 22851-59, 22851-59, 22585, 38220, 20936, 20936-59

Patient #2 2nd sx:
22612, 22842, 20926, 20926-59, 22614, 22614, 22614, 22614, 22614

Just to make sure that I have this correct, the "multiples" use units instead of lines? The insurances are just not paying the procedures.
 
I would definitely bill as units then instead of lines, bcbs will only take units, they deny as a dup if we bill by line.
 
The only thing I would question is billing 20926 twice from what I see, the code is for grafts it is general in nature and may be taken from multiple sites. This code I would bill with a 51 modifier. It is not 51 exempt.
 
Again, a 59 modifier is not being stuck on anything to get it out the door, it depends on what your specific carrier wants. BCBS in Pennsylvania wants units, some specific workers comp carriers want line by line with a 59 on the additional unit code, for example 22614, 22614 59. A 59 on a code does not warrant 100% of allowable payment if billed on 2 primary procedure codes such as 22630 and 63047 59. (You would get 50% of the allowable for 63047). 59 is just being used to indicate that the secondary procedure is being done at a different site, body area or for a different disease or condition. If I would bill 22614 and 22614 59, I would expect 100% of the allowable for both codes as they are both modifier 51 exempt procedures. For more clarification on this issue, and other spinal coding issues, I would suggest attending the American Association of Neurological Surgeons Reimbursement and Coding Challenges educational seminar. Again, in the AANS seminar we are told for 51 exempt codes to either bill as 22614 x 2 or 22614 and 22614 59 depending on your insurance carrier. The presenters at this seminar have a lot of coding experience and some sit on the CPT Assistant Editorial Panel and serve as liasons to the AANS/CNS Coding and Reimbursement Committee so I highly doubt that they would give incorrect advice. Again, I would check with your individual insurance carriers as to how they want additional units billed. Billing as units or billing per line item with a 59 on the second duplicate code is not incorrect coding.
 
One additional thing I am curious about though is using 20926 for spine cases, usually, we uste this code for graft used with crani codes such as Removal of pituitary tumour, 61548. Is your physician using bone graft obtained from the same incision (ribs, spinous prcess or laminar fragments)? Local bone graft would be 20936 and would only be billed once. If he is using morcellized bone graft obtained through the hip, it would be 20937. I would review to see if you are maybe using the incorrect graft code. Any additional questions or if you would like to send me more detail about the graft, please email me at kkemick@tri-state-neurosurg.com.
 
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