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Modifier 59 and bilateral procedures

  1. #1
    Default Modifier 59 and bilateral procedures
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    I have a strange one for you.

    Our BCBS provider pays the highest billed charge as the primary procedure so when billing for bilateral procedures, the charge is doubled sometimes causing the bilateral procedure to be primary when, in fact, it was another procedure with a higher RVU value. It's in they guidelines and our contract with them states we follow the guidelines so that is the way it has been since day one.

    We now have a new boss (not a CPC) and she had us bill a trial one seperating the bilateral procedure code onto two lines with a modifier 59 on the second line. This was successful in that the reimbursement came back the way it should but the coders on staff are not comfortable with this way of coding bilateral.

    As we reviewed of the definition of Modifier 59, we do not feel it is the appropriate way to code. We feel it is being coded this way for more money, which we all know is not the way to code.

    The boss states that BCBS is forcing us to code/bill this way in order to recieve the 'correct' reimbursement.

    Does anyone have any additional thoughts or guidance on this issue? Maybe some official rules or guidelines for us to reference?

    Thanks for any help you can provide.

  2. #2
    Location
    Wilmington North Carolina
    Posts
    22
    Default 59 modifier
    I would encourage you to call BCBSNC and ask to speak with either the Manager of Professional Relations or Medical Director. Unfortunately sometimes your area representative is not able to truly provide the information you need. What you need is someone who really can get to the correct person who developed or implemented the process within the computer system to make claims pay this way.

    You would be considered a hero if you point this out to upper management at BCBS so go for the top. Good luck.
    Susan

  3. #3
    Default
    Thank you for the suggestion.

    So, just to clarify, you agree that this is incorrect coding for bilat?

  4. #4
    Location
    Wilmington North Carolina
    Posts
    22
    Default 59 and bilatera
    Can you give me an example of what and how you are coding and your charges?

  5. Default
    Quote Originally Posted by tgutierrez View Post
    I have a strange one for you.

    Our BCBS provider pays the highest billed charge as the primary procedure so when billing for bilateral procedures, the charge is doubled sometimes causing the bilateral procedure to be primary when, in fact, it was another procedure with a higher RVU value. It's in they guidelines and our contract with them states we follow the guidelines so that is the way it has been since day one.

    We now have a new boss (not a CPC) and she had us bill a trial one seperating the bilateral procedure code onto two lines with a modifier 59 on the second line. This was successful in that the reimbursement came back the way it should but the coders on staff are not comfortable with this way of coding bilateral.

    As we reviewed of the definition of Modifier 59, we do not feel it is the appropriate way to code. We feel it is being coded this way for more money, which we all know is not the way to code.

    The boss states that BCBS is forcing us to code/bill this way in order to recieve the 'correct' reimbursement.

    Does anyone have any additional thoughts or guidance on this issue? Maybe some official rules or guidelines for us to reference?

    Thanks for any help you can provide.
    If it is a bilateral procedure that is being coded, why is the modifier 59 being used rather than modifier 50?
    I worked for an excellent professional billing organization in the past that did bill bilateral procedures differently based on the way the different insurances recognize them. So, for some we billed bilateral on one line, with 2 units, and a modifier 50. For others, we billed them on two separate lines with modifier 50 on the second line. This was because the different insurance companies set up their software to recognize bilateral procedures differently.

    Diana, CPC
    Auditor at Private

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default RT / LT vs 50
    And some payers like two separate lines with -RT modifier on one line and -LT modifier on the other.

    F Tessa Bartels, CPC, CEMC

  7. Default
    Quote Originally Posted by FTessaBartels View Post
    And some payers like two separate lines with -RT modifier on one line and -LT modifier on the other.

    F Tessa Bartels, CPC, CEMC

    Yes, I concur!

    Diana

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