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J code denials:modifier 59 on 94640?

  1. #1
    Melbourne, Florida
    Default J code denials:modifier 59 on 94640?
    Medical Coding Books
    99214 25 dx: 493.90,466.0,401.9,272.4 = paid
    94640 dx: 493.90, 466.0 = paid
    j7609 dx: 493.90 = denied c0-97
    j7645 dx: 493.90 = denied co-97

    should i have billed the 94640 with a 59 modifier?
    Denise Gilrane-Pillow, CPB

  2. Default
    what is the EOB co-97? Not familiar with that one.

  3. Default
    I never bill 94640 with a modifier 59. The E&M visit w/ mod 25 I think is correct.

  4. Default
    59 modifier on 94640 will not result in payment for the drugs. The two drugs were denied as CO97, contractual obliagation (meaning don't bill the patient, check your contract) and 97, short version is that it's included in another service. I'm guessing you billed Medicare, and it is my experience that Medicare does not cover those drugs. It is not a coding issue, from what I see the coding is fine (without reviewing the notes, that is)

  5. #5
    Overland Park, KS
    I'll wager an opinion here.

    While the CPT guidelines direct you to report the appropriate code(s) for the medication used with nebulizer treatments, not all payers will reimburse for them. Some payers consider the medication to be inclusive of the nebulizer treatment.

    With that being said, modifier 59 would not be appropriate in the above scenario. As the person in the above post stated, without having the notes to look at, the coding appears to be correct. This appears to be a coverage issue with the payer and I would recommend consulting with the payer in question for further guidance.

    Hope this helps and again this is my opinion.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  6. #6
    Melbourne, Florida
    yes that helps very much.. I will check with Medicare regarding the usage of the J code (denied co 97) and post their response .. thank you all
    Denise Gilrane-Pillow, CPB

  7. Default denial of J codes CO-97
    CO-97 is a denial of a procedure because it is included in another procedure (including a global package) however that does not apply in this case.

    From what I can gather the ICD code 493.90 is not on the Medicare list of limited coverage diagnosis,. Your documentation would have to support ICD 493.91 or 493.92 (acute condition). 493.90 is unspecified and not on the list.

    I also believe you could bill the 96460 twice because two treatments were administered. if the condition was acute I would appeal the claim.

    Good luck I hope you can be reimbursed appropriately.

  8. #8
    If 94640 was done twice, to the second 94640 should be appended Mod 76.

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