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When McKesson edits contradict commercial insurance AND CMS guidelines

  1. #11
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    Medical Coding Books
    Would it help for your MD ask their MD for a written directive on how future procedures of this type are to be coded and documented when you submit them?
    Ron McKenzie, CPC-A
    Greater Orlando FL Chapter

  2. #12
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    Quote Originally Posted by RonMcK3 View Post
    Would it help for your MD ask their MD for a written directive on how future procedures of this type are to be coded and documented when you submit them?
    No because payers typically will not tell you how to bill to get paid. We have to just code correctly and then work thru the systems of edits that are in place.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #13
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    Quote Originally Posted by ollielooya View Post
    These are great helps everyone, thank you! The only drawback is that there are so many of these type of claims it looks like this would be an ongoing issue. Could we turn this into a contractual issue? And since the doctor is expanding his practice into performing more of these types of treatment, we'd like to be well armed and fortified for dealing with carrier issues. But for the time being going to explore your suggestions! ---Suzanne
    If you have a lot of this type of issue going before the medical director at a plan, chances are there will be changes made in the future. But you can address this issue when contracting with a carrier.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  4. #14
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    This was helpful reading, however this particular LCD seems to indicate that modifier 50 is acceptable. At least that's how I interpret it. ---Suzanne

  5. #15
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    Quote Originally Posted by ollielooya View Post
    This was helpful reading, however this particular LCD seems to indicate that modifier 50 is acceptable. At least that's how I interpret it. ---Suzanne
    Yep, under the CMS guidelines the 50 modifier is allowed to indicate bilateral on that procedure code. Unfortunately, McKesson does not have to follow the CMS guidelines, they can set up their own edits. But when it comes to appealing claims we can sure use the CMS guidelines as a standard of care. Hopefully the McKesson edits do allow the RT and LT modifiers instead.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  6. #16
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    Arlene, thank you for your continual help. I tried emailing you privately thru the forum a while back but not even sure you got my message. Unfortunately with this particular insurance company RT and LT are not recognized for payment utilizing two separate lines, for this CPT code, so you can see the ongoing dilemna. I'm so thankful this thread is staying alive as it's been such a useful tool from which to base the next move. Hopefully, Debra Mitchell will report in as I've been wating to see what she has found out. ---Suzanne

  7. #17
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    Quote Originally Posted by ollielooya View Post
    Arlene, thank you for your continual help. I tried emailing you privately thru the forum a while back but not even sure you got my message. Unfortunately with this particular insurance company RT and LT are not recognized for payment utilizing two separate lines, for this CPT code, so you can see the ongoing dilemna. I'm so thankful this thread is staying alive as it's been such a useful tool from which to base the next move. Hopefully, Debra Mitchell will report in as I've been wating to see what she has found out. ---Suzanne
    Which carrier are you dealing with? Sorry I don't think I got your message before but you can email me directly at smith_arlene@hotmail.com. I check my junk mail all the time to be sure I don't miss messages that might be coding related.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  8. #18
    Location
    Columbia, MO
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    Quote Originally Posted by ollielooya View Post
    Arlene, thank you for your continual help. I tried emailing you privately thru the forum a while back but not even sure you got my message. Unfortunately with this particular insurance company RT and LT are not recognized for payment utilizing two separate lines, for this CPT code, so you can see the ongoing dilemna. I'm so thankful this thread is staying alive as it's been such a useful tool from which to base the next move. Hopefully, Debra Mitchell will report in as I've been wating to see what she has found out. ---Suzanne
    Hang tight I have had some other stuff to deal with but I am close to an answer it may not be what we all want but an answer nonetheless I hope.

    Debra A. Mitchell, MSPH, CPC-H

  9. #19
    Location
    White Plains, NY
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    While awaiting The Answer form Debra (;-) I thought I'd add my two cents.

    I have know quite a few Medical Directors - and it will really depend on them. Some are very understanding and really want to pay the doctor what they deserve (but not a penny more), while others stick to the Letter of the Law and will not budge. I knew one who reveled in his nickname: The Terminator (for teminating so many providers from the plan).

    Good Luck!

    Lin
    CPC, CEMC, CPMA

  10. #20
    Location
    Everett, WA
    Posts
    886
    Default appreciating all the forum input from my colleagues
    Yes, while I'm taking notes and waiting, perhaps another colleague who writes for our Coding Edge magazine, Marvel Hammer might comment. At least I can hope. I think a peer-to-peer review would be a good idea, although I'm sure the provider won't be pleased in having to take up those administrative duties, but if he wants to get paid......
    I'm still awaiting word from the Regional Reps as how to handle this situation,....Could it be that they might not know the answer? ---Suzanne

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