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Insurance company requiring 24 modifier

  1. #1
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default Insurance company requiring 24 modifier
    Medical Coding Books
    I just need to vent about United Healthcare/Medica. Maternity patient sees one of our OB/GYN docs; she also has Factor V Leiden (289.81), so when hospitalized for delivery, our Hematologist/Oncologist sees her to manage that problem. Different specialty, but same Tax ID. Claim denied as part of the global OB. One of the follow up girls calls Medica and is told that it doesn't matter that the doc is a different specialty; if we want it paid, we would need to resubmit with a 24 modifier. I thought that the customer service person she spoke to must have been mistaken - shouldn't need that if a different specialty, right? I called myself, got tranferred up the line - and the only way this will be paid is with the 24 - even though they know it's a different specialty. So I am having her add the modifier and resubmit - but it just burns me to do so - and I used to work for insurance companies (more than one)!! AARGH!!!
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

  2. #2
    Location
    Kansas City, MO
    Posts
    434
    Default
    You're coding logic is absolutely right...but as a former employee of an insurance company as well, you gotta know they don't always think like coders, especially when it comes to their claims systems. Wrong or not, atleast they told you how to get it through their system. Some payers just say "thats not correct, but I can't tell you how to code".
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

  3. #3
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default
    So true, so true. One nice thing about the last insurance company I worked for - they used me for coding reviews, to help set the edits in the claims system, and even to build benefits so the correct procedure and diagnosis codes were behind the benefit. Of course, that was a small, local company!

    One of our other insurance companies says that if the patient saw anyone of any specialty with the same tax ID, they are no longer a new patient. We just deal with it and re-code to an established.

    I feel better this morning!
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

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