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Tricare and B/L procedures

  1. #1
    Jacksonville Beach, FL
    Default Tricare and B/L procedures
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    For some time now (1-2 years) Tricare has been paying 100% for some B/L procedures, such as Blephs and Breast reductions, instead of paying 100% then 50% they pay 100% for each procedure. Now they are requesting refunds on these claims. Has anyone run into this and/or know where I can find a list of codes that are not subject to the reduction? Thank you for any input.

  2. Default
    We have to bill our bilateral procedures to tricare on one line with a 50 modifier. We can't bill 2 lines otherwise the payment is incorrect. We were told by tricare to just bill on one line with a 50 modifier and keep the units as "1". They then reimburse correctly at 150%.

  3. #3
    I'm not sure what region you are in but I'm in Arizona and our Tricare region requires us to bill on two line items with RT and LT modifiers and I have never had an issue with them paying incorrectly in respect to multiple line items.

    Wow, I'll have to keep an eye out now.

  4. #4
    Jacksonville Beach, FL
    I'm in Florida, so it's South Region. I bill 2 lines using RT and LT. Thanks for the input. It's hard to get somebody who knows how they supposed to pay @ Tricare; they just refer me to the CMAC, prevailing rates and manual. I just cannot find anything in the manual that will list any procedures that are not reducible for procedures. I'm guessing they will just follow Medicare.

  5. #5
    I believe that Tricare does follow Medicare guidelines.

    Now for the BIG question??? Why was this not caught when the payments were posted and refunded to them or questioned at that time? 1-2 years of overpayments is not going to be pretty especially if you have a large Tricare case mix.

    Yikes..glad I'm not in your shoes!
    Mary, CPC, CANPC, COSC

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