Wiki 45380 denied

[CBarry21]

I was wondering if this code will be denied "Payment based on maximum allowable amount." if the PT modifier is not added to it when a biopsy is collected. They put an allowed amount but then put it under not covered and change the full charge amount over to the patient.
Thank you in advanced

 

[thomas7331]

I was wondering if this code will be denied "Payment based on maximum allowable amount." if the PT modifier is not added to it when a biopsy is collected. They put an allowed amount but then put it under not covered and change the full charge amount over to the patient.
Thank you in advanced

Under the Affordable Care Act, a screening colonoscopy should be covered in full by insurance plans with no patient responsibility. If a biopsy was done, some payers may still pay it correctly based on a screening diagnosis code, but others may need the PT modifier in order to be able to identify the service as a screening. So if the modifier is omitted in error, it is possible that the claim will deny.

But if the procedure was not a screening test, a PT modifier can't be added, and whether or not the colonoscopy will be denied just depends on the payer's policies and the terms of the patient's benefit plan.