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Modifiers - denial from Medicare

  1. Default Modifiers - denial from Medicare
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    I had a denial from Medicare for the following claim. Can anyone help as I need to get this resubmitted and I cannot figure out what they want?

    On 9/26 the patient falls requiring an open reduction, internal fixation of her left hip, but she was already scheduled to have a hip revision on her left, so it is postponed. We bill for both the operating surgeon and an assistant surgeon on the open reduction, internal fixation. Then on 10/5 the patient is returned to the operating room and has the revision done on her right hip. Medicare pays for the original surgery on 9/26 surgery. We now bill a 27132-80-79-RT for the assistant surgeon on 10/5 and it is rejected. They are saying missing/incomplete/invalid HCPCS. I have been taught that the 80 goes first as it is a pricing modifier, then the 79 as a statistical and the RT. Does anyone know different? Please help.

    Thanks,

    Zoe

  2. #2
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    Quote Originally Posted by zvankleek1 View Post
    I had a denial from Medicare for the following claim. Can anyone help as I need to get this resubmitted and I cannot figure out what they want?

    On 9/26 the patient falls requiring an open reduction, internal fixation of her left hip, but she was already scheduled to have a hip revision on her left, so it is postponed. We bill for both the operating surgeon and an assistant surgeon on the open reduction, internal fixation. Then on 10/5 the patient is returned to the operating room and has the revision done on her right hip. Medicare pays for the original surgery on 9/26 surgery. We now bill a 27132-80-79-RT for the assistant surgeon on 10/5 and it is rejected. They are saying missing/incomplete/invalid HCPCS. I have been taught that the 80 goes first as it is a pricing modifier, then the 79 as a statistical and the RT. Does anyone know different? Please help.

    Thanks,

    Zoe

    Just my thoughts... We don't use statistical modifiers on our assistants' claims to Medicare. Our MAC is Pinnacle, so yours may have different requirements. But may be something to consider, as far as making changes.

    Hope this helps
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

  3. #3
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    Columbia, MO
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    Just a thought but I think the 79 is the more meaningful pricing modifier since it is the one that will pull the procedure out of the global and allow it to be considered for payment then the 80 for the assistant reduction. That is how I would do it.

    Debra A. Mitchell, MSPH, CPC-H

  4. Default
    Meagan, you were correct. We just heard back from CMS and they stated that the 79 modifier was not needed with the assistant surgeon and we should only use the 80. Thanks to all.

  5. Default
    I agree with Debra, in PA we would bill the claim with the 79 first then the other modifiers. (With our carrier for the physician assistant we would bill this as 79 82 AS).

  6. #6
    Location
    Baton Rouge
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    What I've been told, and remember reading, about modifiers on assistants' charges, is that assistants' fees don't include global payment, since they generally don't do the pre- and post-op care. Therefore, no "global" modifier is needed. Their surgical fees are already reduced, and should not be reduced any further.
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

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