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I have several claims for skin grafts on a patient who is in a global period for placement of an autograft 15100-15121. As the patient has over 50% TBSA burns, he has multiple grafts and is going to the OR every 3 or 4 days to treat a different area of the body with either artificial skin grafts or autografts. Claims submitted to American Equity (they are connected to OWCP federal work comp) who has denied all of my claims following the one that put the patient into a 90 day global. Per the rep I spoke to at Conduent, the modifier 58 which I billed on subsequent grafts is NOT payable per the OWCP fee schedule.
When I pulled the fee schedule, it is showing me that CPT codes 15002, 15003, 15004, 15005, 15111, 15116, 15101, 15121, 15272, 15274, 15276, and 15278 for grafting are ONLY payable with modifier 76/77 or with NO modifier. CPT codes 15110, 15115, 15100, 15120, 15271, 15273, 15275, and 15277 CAN be paid with mods 58 or 78. My question is HOW can I appeal these services? They aren't following the AMA rules when it comes to use of modifiers. I verified they have the same global periods as what CMS uses so if I bill with no modifiers they will deny for billed within global period.
I have over $55K in surgeries that I cannot just write off but I am not finding anything valid for an appeal except for trying modifier 76/77 - repeat procedure which technically isn't correct. Can anyone give advice on how to proceed? I am stumped and only want to appeal these claims once if possible.
Thanks!
When I pulled the fee schedule, it is showing me that CPT codes 15002, 15003, 15004, 15005, 15111, 15116, 15101, 15121, 15272, 15274, 15276, and 15278 for grafting are ONLY payable with modifier 76/77 or with NO modifier. CPT codes 15110, 15115, 15100, 15120, 15271, 15273, 15275, and 15277 CAN be paid with mods 58 or 78. My question is HOW can I appeal these services? They aren't following the AMA rules when it comes to use of modifiers. I verified they have the same global periods as what CMS uses so if I bill with no modifiers they will deny for billed within global period.
I have over $55K in surgeries that I cannot just write off but I am not finding anything valid for an appeal except for trying modifier 76/77 - repeat procedure which technically isn't correct. Can anyone give advice on how to proceed? I am stumped and only want to appeal these claims once if possible.
Thanks!