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Thread: ongoing billing issues with major carrier

  1. #1
    Join Date
    Apr 2007
    Everett, WA

    Default ongoing billing issues with major carrier

    AAPC: Back to School
    I've posted this before but it still remains an ungoing issue, so hopefully someone can answer here or behind the lines. What to do when CMS states a certain modifier is allowable (50), carrier policy also states it is allowed and customer service reps state they follow CMS guidelines. But according to older CPT Assistant directives, the carrier is saying modifier 50 is NOT allowable? So basically policy directives are trumped and overuled by the AMA/CPT directives. Is this correct? And if so, shouldn't the carrier basically review their company policy so that incorrect information is not fed to the providers? Am getting help from upper end Provider Service Report, but it seems they are waffling on whether a takeback is appropriate or not since discussion of these issues are scheduled in the near future. How much more proactive can one be? Basically is there any more we can do other than to wait? (in the light of many more claims pending to go out).

    Please, any folks out here who have had to tread these waters and can toss a life jacket our way?

    ---Suzanne E. Byrum CPC

  2. #2
    Join Date
    Apr 2007
    Concord, NC or Rochester, NY


    Be a little more specific. Your rambling above is confusing.

    Insurance carriers can set their own policies and sometimes when it comes to modifier 50, they will not accept that as they want a RT/LT on two separate lines. I have even seen where they consider the procedure bilateral when in fact CPT indicates it is not bilateral.

    Sometimes it is best to have the MD call the Medical Director as occasionally the doctor to doctor discussion gets things accomplished a lot faster. Just make sure the MD has the facts and understands the issues - coach the MD.

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