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When McKesson edits contradict commercial insurance AND CMS guidelines

  1. #1
    Location
    Everett, WA
    Posts
    886
    Default When McKesson edits contradict commercial insurance AND CMS guidelines
    Medical Coding Books
    Ok, how does one go about resolving issues when a claim is denied for incorrect surgery-modifier combination when using -50 with 64612? I verified it as assignable with MCR status indicators and also with the major carrier who is refusing payment whose own policy states that it is allowed. Provider Relations basically said they can't help and recommended we file an appeal with supportive documentation. Yikes! I pulled up documentation to that effect and sent it certified mail. I tried "playing" with the McKesson edits at the website and there is no conceivable way to get it to accept a bilateral modifier. So, basically it looks like 1) we bill without modifier and accept the payment, 2) bill with modifier 50 and receive the rejection to 3) followup with claim action request, and if that doesnt' resolve the issue.......4) appeal...and then what? Perhaps the code descriptor is what triggers the edit by AMA standards? Just not sure.

    Is there an alternative fix to this messy issue? Any input from those of you who may have encountered a similar situation with the editis even if it regards a different code?

    ---Suzanne E. Byrum CPC

  2. Default
    Hello,

    A piece of information from Internet; I hope this helps -

    Medicare payers will allow reimbursement for a single unit of 64612 per site. For example, if the neurologist uses Botox to treat blepharospasm with injections into the skin around both eyes, you would use 64612 with modifier -LT (Left side) on the first line of the CMS-1500 form and 64612-51-RT (Multiple procedures; Right side) on the second line to show that you have performed the procedure bilaterally. However, if the neurologist administered more than one injection on the same side, you may still only report a single unit of 64612;

    Since, I don't have a new thread option I am asking one question here:
    I am looking forward to work from home as a coding consultant;
    How am I to post this information in the forum to enable many persons respond?

    Thanks and Regards,
    LMohan

  3. #3
    Location
    Everett, WA
    Posts
    886
    Default
    Thank you so much for your response. Unfortunately, the edits will block and not allow the use of modifier 50, and that's my point. We're instructed by policy and guidelines to do it this way, but the edits bounce it from Colorado to the Pacific Ocean. Hopefully our appeal with policy/documentation proof will over-ride but from what I've learned from Provider Relations and others, this is highly unlikely. That is why I submitted the original question.

    Now you can post your question in the general category (all things coding), but you might want to do a search in the archives first to see the response to similar questions such as yours. Once you dig around in the forums you might find the best place suited to fit your request. Questions such as yours appear quite frequently, so it should be easy to pull up. I work from home, but my situation in acquiring this position is not the normal route most are required to take. (which is too long for this thread.)

    ---Suzanne E. Byrum CPC
    Everett, WA

  4. #4
    Default
    Hello, I'm hoping I might be able to shed some light on this one. In the state of CT, the LCD article states that you can't use the bilateral modifier for 64612. Here is a link:

    http://www.cms.gov/medicare-coverage...s=9&IsPopup=y&

    If that link doesn't work, I found it under article: A46164.

  5. #5
    Location
    Columbia, MO
    Posts
    12,843
    Default
    Quote Originally Posted by ollielooya View Post
    Thank you so much for your response. Unfortunately, the edits will block and not allow the use of modifier 50, and that's my point. We're instructed by policy and guidelines to do it this way, but the edits bounce it from Colorado to the Pacific Ocean. Hopefully our appeal with policy/documentation proof will over-ride but from what I've learned from Provider Relations and others, this is highly unlikely. That is why I submitted the original question.

    Now you can post your question in the general category (all things coding), but you might want to do a search in the archives first to see the response to similar questions such as yours. Once you dig around in the forums you might find the best place suited to fit your request. Questions such as yours appear quite frequently, so it should be easy to pull up. I work from home, but my situation in acquiring this position is not the normal route most are required to take. (which is too long for this thread.)

    ---Suzanne E. Byrum CPC
    Everett, WA
    I agree you should be able to use the 50 but it is also acceptable to use 2 lines with an RT on one line and an LT on the other and not use the 50 at all. Are you saying your software will not allow this either?

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Location
    Columbia, MO
    Posts
    12,843
    Default
    Quote Originally Posted by ollielooya View Post
    Ok, how does one go about resolving issues when a claim is denied for incorrect surgery-modifier combination when using -50 with 64612? I verified it as assignable with MCR status indicators and also with the major carrier who is refusing payment whose own policy states that it is allowed. Provider Relations basically said they can't help and recommended we file an appeal with supportive documentation. Yikes! I pulled up documentation to that effect and sent it certified mail. I tried "playing" with the McKesson edits at the website and there is no conceivable way to get it to accept a bilateral modifier. So, basically it looks like 1) we bill without modifier and accept the payment, 2) bill with modifier 50 and receive the rejection to 3) followup with claim action request, and if that doesnt' resolve the issue.......4) appeal...and then what? Perhaps the code descriptor is what triggers the edit by AMA standards? Just not sure.

    Is there an alternative fix to this messy issue? Any input from those of you who may have encountered a similar situation with the editis even if it regards a different code?

    ---Suzanne E. Byrum CPC
    Suzanne can I ask exactly what was injected in other wrods what does the procedure note state, I have a thought here and it is a good one but iI want to know what the note says first.

    Debra A. Mitchell, MSPH, CPC-H

  7. #7
    Location
    Everett, WA
    Posts
    886
    Default
    I'm so pleased to see some responses to my earlier thread posted 3 months ago. Thank you! Still dealing with this issue. Debra, our software has no issues with sending out separate line services with modifer 50 OR 2 lines with RT and LT. It's just that the insurance company will not accept it, and use the CPT Assistant rules in denying, despite what MCR allows and their own regional policy. So, it doesn't matter at all what the other insurance companies allow whether they be commercial or governmental, they WILL not process this code for bilateral charges, You asked about what was being injected, here's an extraction: ( Botox (J0585) is being administered for spasmodic torticollis at the physician'soffice). Patient was consented for injection of Botox. The risks of the procedure were explained to her. The following muscles were injected:

    Procerus one injection, 5 units

    Corrugator 2 injections on each side, each injection 5 units

    Frontalis 5 injections on each side, each injections 5 units

    Temporalis 3 injections on each side, one injection 10 units and two injections 7.5 units each

    Occipitalis one injection on each side, each injection 10 units

    What is your idea? I can hardly wait to hear whether it's favorable or not!

    ---Suzanne E. Byrum CPC

  8. #8
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by ollielooya View Post
    I'm so pleased to see some responses to my earlier thread posted 3 months ago. Thank you! Still dealing with this issue. Debra, our software has no issues with sending out separate line services with modifer 50 OR 2 lines with RT and LT. It's just that the insurance company will not accept it, and use the CPT Assistant rules in denying, despite what MCR allows and their own regional policy. So, it doesn't matter at all what the other insurance companies allow whether they be commercial or governmental, they WILL not process this code for bilateral charges, You asked about what was being injected, here's an extraction: ( Botox (J0585) is being administered for spasmodic torticollis at the physician'soffice). Patient was consented for injection of Botox. The risks of the procedure were explained to her. The following muscles were injected:

    Procerus one injection, 5 units

    Corrugator 2 injections on each side, each injection 5 units

    Frontalis 5 injections on each side, each injections 5 units

    Temporalis 3 injections on each side, one injection 10 units and two injections 7.5 units each

    Occipitalis one injection on each side, each injection 10 units

    What is your idea? I can hardly wait to hear whether it's favorable or not!

    ---Suzanne E. Byrum CPC
    This might be the type of claim that needs the assistance of the physician. Your physician can request to speak to the medical director for that plan. Sometimes when you get physician to physician appeals you can get an override of the built in edits. Check the appeals process and see how you go about getting all the way to the top.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  9. #9
    Location
    Concord, NC or Rochester, NY
    Posts
    154
    Default
    In these situations, I have found that the MD talking with the Medical Director of the insurance company usually gets it paid immediately. Just make sure to provide the MD with the information necessary for the discussion and perhaps be in the room or on a conference call with the physician. An MD appealing directly has almost always worked in my experience.

    Remember the insurance carrier personnel have a script and do not know what to do beyond that so appeal is usually the way to get around it.

  10. #10
    Location
    Everett, WA
    Posts
    886
    Default
    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

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