Wiki modifier with 32555 (thoracentesis)???

[jennifernelson20]

Do I need LT or RT modifier with thoracentesis? I know i need mod 25 on the visit if inpatient or same day as office visit, but I'm getting a new denial for the wrong modifier........

 

[trarut]

So you used LT or RT and got a denial? Are there any other services you're billing for on that day?

I don't recall that I've ever used laterality modifiers on thoracentesis and, since they're informational, I wouldn't expect a denial. I'd expect the payer to ignore it if I submitted and they don't need it. Have you checked the payer website for a policy that might be related to the denial? It's like a reimbursement policy, rather than a coverage policy but that depends on the insurance company.

 

[jennifernelson20]

So you used LT or RT and got a denial? Are there any other services you're billing for on that day?

I don't recall that I've ever used laterality modifiers on thoracentesis and, since they're informational, I wouldn't expect a denial. I'd expect the payer to ignore it if I submitted and they don't need it. Have you checked the payer website for a policy that might be related to the denial? It's like a reimbursement policy, rather than a coverage policy but that depends on the insurance company.

I did not use the LT/RT, but it was suggested to me. I have never needed a modifier either thats why im so confused. what i billed for that day was 99232 w/ 25 mod and 32555. nothing else. I will see if i can find someone to help me with the payer policy stuff. i cant remember which insurance it is, but its either Humana or United Healthcare.

 

[trarut]

Jennifer, did the 99232 pay or did both lines deny? I'm questioning if the problem lies in the 25 modifier on the 99232 and if the payer has 32555 incorrectly flagged as a major procedure recently.

Many of the payers are starting to tighten their correct coding policies and we're noticing them applying edits they haven't used before.

I found these for Humana, no log in necessary: https://www.humana.com/provider/medical-resources/claims-payments/claims-payment-policies and search "modifier". There are multiple policies for specific modifiers but there is also a "Common CPT and HCPCS modifiers" document that may be helpful. There is also a Claims processing edits page at https://www.humana.com/provider/medical-resources/claims-payments/processing-edits# that may be helpful. I ran your two codes through the Humana Code Edit Simulator in Availity and no edits were produced.

UHC has this document https://www.uhcprovider.com/content...bursement/UHCCP-Modifier-Reference-Policy.pdf that lists the reimbursement policies to review for the specific modifiers. You can search the website for any of the listed procedures.

Hope this helps!

 

[mk2001]

I did not use the LT/RT, but it was suggested to me. I have never needed a modifier either thats why im so confused. what i billed for that day was 99232 w/ 25 mod and 32555. nothing else. I will see if i can find someone to help me with the payer policy stuff. i cant remember which insurance it is, but its either Humana or United Healthcare.

We started getting denials for the same reason from different insurances that never needed an anatomic modifier before. Now, if a 50 modifier is allowed on a code, we attach LT or RT modifiers. Bilateral surgery is allowed for 32555.
Hope this helps.