• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Surgery Denials Need HELP!!!

N

Ninnin

New
Messages
4
Location
Stoneham, MA
Hi everyone any help or guidance would be greatly appreciated!!

I have 3 claims that are denying for procedure/modifier issues, and I am at a loss. I am newer to podiatry, and these surgeries are giving me so much issue and my providers are getting discouraged.

Case one (DK) HARVARD PILGRIM

28297-LT; M20.12 LINE ITEM PAID
28308- LT-59- M19.072 DENIED FOR PROCEDURE MODIFIER INVALID
28285-TA-59; M20.42 DENIED PROCEDURE INCONSISTANT WITH MODIFIER

I HAVE TRIED JUST LT MODS, T MODIFIERS, CHANGED OT MOD 51 AND NOTHING.

CASE 2 (MR) WELLPOINT MASSACHUSETTS

28297-RT; M20.11- DENIED FOR PROCEDURE MODIFIER INCONSISTANT
28308-RT-59; M21.6X1- PAID
28286-RT-59; M20.41- DENIED FOR PROCEDURE MODIFIER INCONSISTANT
 
Did you run these through an edit checker like Encoder Pro or the health plan's edits? Your providers are right to be frustrated. Do you have a mentor or senior foot and ankle coder? This can be a difficult specialty when you are new to coding. Was an anatomical picture of the feet/foot used while reading the op notes to learn and understand the locations of the procedures? That can really help when learning these. You also need to understand and learn the terms and the bones/joints/tendons/ligaments of the F&A. Were the op notes clear, descriptive, and complete?

On the first one, why would 28285 be reported on the great toe along with 28297? Doesn't make sense. 28285 is lesser toes, usually the second toe for hammertoe. 28297 includes a 1st MT & cuneiform fusion.
28297 - Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method
If IP fusion of the Great Toe really was done at the same time (weird), it would be 28755. Unusual though. The 59s and coding itself is your issue. Where was the osteotomy done, which lesser MT?

On the second one, maybe that plan wants the T mods for the great toe. This is not "correct" according to CPT modifiers but sometimes it happens where they want the T rather than the RT/LT.
28286 was really done? If it really was then the M20.41 is incorrect for a cock-up 5th, different ICD. Could be that or could be the RT, they would want the T mods for this procedure. But, did the provider really do that (cock up w/ plastic skin closure)? Unusual again. 59s might also be the issue here.

Modifier 51s are pretty much useless and kind of pointless nowadays because systems automatically rank codes based on RVUs anyway and handle multiple procedure reductions automatically. Medicare and many other plans don't even want the 51. (Example: https://med.noridianmedicare.com/web/jeb/topics/modifiers/51). Unless the plan being billed specifically tells you to use it, it wouldn't matter probably.

You have CPT coding issues here, not simply the modifiers. Would have to see the op notes but I don't think these are coded correctly just looking at the CPTs.
Also, you are going to need an AAOS GSD for doing foot and ankle surgery (any orthopedic surgery really).

 
You must log in or register to reply here.
Top