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Mcare replacements denying heart caths with stents

  1. #1
    Question Mcare replacements denying heart caths with stents
    Medical Coding Books
    I know that starting the 2nd quarter of 2011 that I now need a 59 modifier on the heart cath code when I bill a coronary stent also. BUT....all of a sudden the UHC based Medicare replacement policies (Secure Horizons, AARP Medicare Complete, Evercare) are denying the cath codes when I bill them with stents for some reason.

    For example, I bill 92980 and 93458-26,51,59 (like I do for every other carrier) and they deny for "unbundled" procedure. So at first I removed the 59 thinking that they don't want that, but then they denied it again for the same reason. So now I removed the 51 and put the 59 back and am waiting to see what happens now.

    Anyone else having this problem the last few months with just these few Medicare replacement plans? Seems like something changed when the April 2011 CCI edits started requiring a 59.

  2. #2
    We are having the same problem with the same insurance compaines you are. We are calling UHC tomorrow. I will let you know if we find anything out. I am in Florida, where are you at?


  3. #3
    Great thank you! I'm in Florida also.

  4. Default
    I am in Texas, same problem. Let me know what you hear!

  5. #5
    I use the 26, 59 only and we have no problems here in Arizona.

    Kristin Felty, CPC, CCC

  6. #6
    Default Now PUP is doing this!!!!
    I have an EOB today where PUP Medicare HMO is denying the cath codes wtih -5159 modifiers on them saying "compound with comprehensive".

    I'm so frustrated having to guess which modifier to remove and keep rebilling them.


  7. Default
    I'm confused as to why you bill out with the modifier 51. If the doctor is preforming a cath and it is a true diagnostic cath (new onset of symptoms or a cath hasn't been preformed in 6 months) the modifier 26,59 should get paid. That 59 modifier is telling the insurance that the doctor couldn't do the stent without doing the cath first (distinct procedural service). This usually gets paid no question with UHC Medicare plans for us in NY. There are times when I do get the unbundled procedure denial and I will appeal it with the office note and cath report which shows that the doctor is doing a diagnostic cath and it gets paid. Hope this helps!

  8. #8
    Thank you that helps alot. I always thought I had to put a 51 on each additional procedure so that's why I've always billed this way. Everyone else has always paid it until recently. So I don't need a 51 for ANY insurance?


  9. #9
    Hi... we never use modifier 51 for Medicare. Per TrailBlazer Modifiers Manual, "The standard Medicare system handles multiple surgery logic automatically without the presence of a 51 modifier. The use of modifier 51 is not required to report multiple surgeries.".

    As for other insurance, I use modifier 51 for multiple surgeries.
    Last edited by CMB0704; 07-26-2011 at 09:22 PM.

  10. #10
    Phoenix, AZ
    I'm in AZ also. We use 26 and 59 and are paid without problem.

    Good luck,
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

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