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Line item denial for 64484

  1. Default
    Medical Coding Books
    Since this is a Medicare patient, CCI edits apply. I've been coding spinal injections since 2003 and have never had to attach a mod 59 to the codes submitted by jsolares. My opinion is that if Medicare has denied payment on a code that does not require a modifier you need to call Medicare to resolve the problem. Bottom line is that we don't always get paid by Medicare as quickly as we'd like.

  2. #12
    Location
    Columbia, MO
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    I really hate to belabor this point but the fact is that CCI edits are not the issue nor is the fact that the patient is or is not a Medicare patient. The original question was in regards to 64483, 64484, 64484.
    And the fact that the 2nd 64484 was rejected for payment. The first 64484 needs no modifier but the 2nd one does since it is a duplicate code. This is absolutely appropriate use of the 59 modifier to allow proper adjudication of the claim. There is no reason to let a claim deny or reject before you "fix" it. I too have coded spinal procedures for about 20 years now and I have always listed them in this fashion for all payers in many different states. We use modifiers when we need them for clarity on the claim, not just for CCI edits. I really hope this clarifies the issue for everyone.

  3. Default
    I disagree. CCI edits are the point in this instance and determine the proper use and necessity of modifiers for Medicare patients. This claim has already been rejected by Medicare so now it needs to be "fixed". Yes, we use modifiers for clarity and for Medicare patients CCI edits determine how that clarity is applied. In this instance the edits indicate no modifier should be necessary so a call to Medicare does not seem unreasonable to me. My last input on this one.

  4. #14
    Location
    Columbia, MO
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    12,836
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    CCI edits do not determine proper use of a modifier. CCI edits let us know when two codes are not considered medically indiciated to be performed together as separate procedures. Anytime documentation supports the use of a modifier we should use it. We do not need CCI edits to tell us to use a 50 or 52 or 22. Or if a physician does identical lesion excisions in the same area they are not bundled but they are duplicate codes and yet we put a 59 on. I know you have said this is you last input. However I still maintain that to use the 59 to indicate distinct and separate procedure as in separate level in this case is exactly why the 59 modifier is there for us to use. I apologize if anyone is the slightest bit offended by these posts it was never my intention, I was only trying to educate. Thank You
    Debra Mitchell, MSPH, CPC-H

  5. #15
    Location
    Albany, New York
    Posts
    457
    Default
    I'm sorry, but I have to disagree with mitchellde.

    Just because a CPT is listed twice on a claim does not indicate the use of modifier 59.
    If the carrier understands CPT descriptions, the use of modifier 59 in this scenario should not be an issue.
    I have never received edit when I've coded 64484 as two separate line items.
    Karen Maloney, CPC
    Data Quality Specialist

  6. #16
    Location
    Denver Colorado
    Posts
    281
    Default
    What is the basis for "If you bill with units it is incorrect, units cannot be greater than one for this procedure."?

    The code description is "each additional" and can be billed with units of service. In fact some payers prefer providers to report with the units of service field rather than separating the additional levels into separate line items.

  7. #17
    Location
    Columbia, MO
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    12,836
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    In the 1500 billing manual it states that units cannot be greater than one unles the code comes as quantities such as drugs or timed services. Each is not a quantity, and the rest of the code states to list separately. Many times when using units either the payment is incorrect or a denial is issued for units out of range. I know a lot of people bill this way however it is incorrect.

  8. #18
    Location
    North Carolina
    Posts
    3,126
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    Not trying to sound like a devils advocate but I do have one carrier that tosses this ideology out the window. Our BCBS carrier requires 2 units when billing for bilateral procedures (example-20610-50). Below is an excerpt from their billing/coding manual.......

    "Modifier -50 should be used for bilateral procedures. Bilateral procedures should be listed on the claim as a single line item, with modifier -50, and a two in the units field."

  9. #19
    Location
    Columbia, MO
    Posts
    12,836
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    Pretty humorous actually! They should read the 1500 billing manual. However when you have it writing from a payer then it is suposedly correct to list it their way. Too many times I have observed that using units is the way people are taught or the billing software tells them so. And this is what will cause unecessary underpayments and denials, that is why I teach it strictly from the 1500 instructions, then make the payer cough up something in writing.

  10. Default
    I agree with Guru too, I just attended an AAPC audio-conference for pain mgmt and we should append mod-59 to the 3rd level in this code scenario per AAPC instructions, so the coding should look like this:
    64483, 64484, 64484-59, 27096 and 77003-26

    Erika.

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