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Medicare Denials

  1. #1
    Unhappy Medicare Denials
    Medical Coding Books
    I billed M'care for the following procedures 69100x2 w/ a modifer -50.
    They came back and denied the claim with the following reason:
    The procedure code is inconsistent with the modifer used or required modifer is missing.

    Can someone please give your suggestion in regards to a modifer or if no modifer should have been used. Could I have just used a -59?

  2. #2
    Default BX External Ear
    Medicare should accept the modifier 50 - however each MAC can process diffferently. You should check to see if your MAC has specific instructions on how to bill for this procedure. Modifier 59 will also work but 50 is more specific, which is the purpose of the modifier.

  3. #3
    Greeley, Colorado
    I think -59 is most appropriate since you are doing separate lesions. According to Trailblazers (J4 MAC), bilateral is not appropriate.
    Lisa Bledsoe, CPC, CPMA

  4. #4
    North Carolina
    CMS fee schedule has a payment indicator of 0 (zero) for 69100.

    0=Do not use modifier 50

    Depending on your carrier, you may need to use 59 to denote a separate biopsy.

    **Just saw Lisa's post---I agree **

  5. #5
    Default Opsi
    The outpatient status indicator in addendum B is "T" so I guess it just depends on what type of service you are billing (i.e. physician or facility - outpatient).

  6. Default
    CPT 69100 is not inherently bilateral, modifier 50 is not applicable, modifer 59 is appropriate for the 2nd procedure.

    CT ENT

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