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95904 as 12 units

  1. #1
    North Carolina
    Default 95904 as 12 units
    Medical Coding Books
    Our physician performed 12 units of 95904. I know that Appendix J of the CPT code has a recommendation of 6 units for bilateral CTS testing. I wanted to seek some opinions and see if anyone was using modifier GD.

    GD="Units of service exceed medically unlikely edit value and represents reasonable and necessary services."

    Also, I've been reading a great deal of literature on Neurodiagnostic testing and wanted to get some input on how you bill the units when they are in excess of the recommendation allowance. In my scenario, I could bill...

    1) 95904 x12 units on a single line or 2) separate the sensory NCS into two line items, such as 95904 x6 on one and 95904 x6 on the other. (with modifier 59 on the 2nd line)

    The thought was that 95904 x 6 and 95904 x 6-59 would be a better coding scenario since a payer is likely to deny all 12 units instead of allowing 6 units and denying 6. I'm hearing that many payers will process the first line and deny only the second line for the additional units. This only need to work those units that are out of the "norm" and appeal the remaining with medical necessity.

    Anyone experiencing this?

  2. #2
    Columbia, MO
    When we tried billing these codes with units greater than one, every claim failed for units out of range. Then we started billing each line item with one unit and used the 59 modifier, and every line item paid. This was Medicare as well as every commercial carrier we used. I had experienced the same thing many years ago when I worked in the facility, and had the same outcome. Just my 2 cents here.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    North Carolina
    Thanks Debra...We're not experiencing issues with units of 6 or under. I've checked our LCD and it appears that our particular Medicare carrier had adopted CPT's table of recommendation. I'm really intrigued by the GD modifier and it's acceptance by the carriers...

  4. #4
    North Carolina
    No one else deals with this procedure?? Interesting............

  5. #5
    We bill this code to Medicare and others and have had no trouble getting paid for multiple units, but we rarely exceed 4 units. I have no experience with the modifier you mentioned.

  6. #6
    North Carolina
    Thanks for your feedback...

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