# Line item denial for 64484



## jsolares

Hello,

I billed out the following procedure codes to Medicare: 64483, 64484, 64484, 27096 and 77003-26.
Medicare paid all except for the 2nd 64484.  Can this be appended 
with a "59" modifier?

Thank you


----------



## michele3667

*Denial of 64484*

Appending modifier -59 would not be appropriate. You need to make your quantity 2 units when billing out.


----------



## magnolia1

Description for 64484 is "each additional level".
Do not have to amend modifier 59 to that code.


----------



## jsolares

Great, thanks for your help...


----------



## mitchellde

I agree we should not have to append the 59 to the 64484 however when you list it twice it will edit out as a duplicate entry so append a 59 to the secon d 64484 and it will be fine.  If you bill with units it is incorrect, units cannot be greater than one for this procedure.


----------



## coderguy1939

What was the reason for the denial?  Our FI wants LT or RT for injections administered unilaterally.  Mod 59 is not required and although it would probably get it paid, is an inappropriate use of the modifier--something to be avoided with Medicare (or any other carrier).


----------



## mitchellde

Where did you get the information that this is inappropriate usage of the 59?  It is not.  The LT and RT modifiers are for anatomic specificity, the 59 is the modifier that identifies distinct and separate.  When the code states each additional level I agree that it should be implicit with the code that each one listed is a different level, however this is why we have modifiers, when you list an identical code twice we need to alert the payer that this is for two distinct and separate procedures, hence the 59.  If each additional level were on say the LT side you would still need the 59 to indicate separate level.  This is in no way non compliant for Medicare or any other payer, it is appropriate usage of modifiers to indicate what was done.  If you have information from the AMA or CMS to the contrary I hope that you will share this.


----------



## coderguy1939

CCI edits indicate that these codes are not bundled so they should be paid without the use of mod 59.  If a modifier is not necessary then the answer lies elsewhere.  I don't know why this was denied or if Medicare was contacted to find out how to resolve the denial.  We have this happen occasionally and usually end up appealing the denial per our FI's instructions. I would not use mod 59 in this instance unless otherwise instructed by Medicare. You can get info on use of mod.59 at the Medicare Learning Network.


----------



## mitchellde

No you are right they are not bundled that was not the purpose of the modifier.   Anytime you list the same code twice on a claim you need a modifier to indicate separate site or separate time of day, there is nothing on the Medicare learning network that indicates or implies that using a 59 to indicate separte level is inappropriate.  CCI edits are not the only reason we use modifiers.  My objective as a coder is to code what is documented and to do so in a manner as to indicate to the payer what was done to obtain optimal and timely reimbursement.  So I maintain there is absolutely nothing incorrect or noncompliant with putting a 59 modifier on a duplicate line item to indicate separate service.  Nor is there any instruction that prohibitis this.


----------



## tadavis

I agree


----------



## coderguy1939

Since this is a Medicare patient, CCI edits apply.  I've been coding spinal injections since 2003 and have never had to attach a mod 59 to the codes submitted by jsolares.  My opinion is that if Medicare has denied payment on a code that does not require a modifier you need to call Medicare to resolve the problem.  Bottom line is that we don't always get paid by Medicare as quickly as we'd like.


----------



## mitchellde

I really hate to belabor this point but the fact is that CCI edits are not the issue nor is the fact that the patient is or is not a Medicare patient.  The original question was in regards to 64483, 64484, 64484.
And the fact that the 2nd 64484 was rejected for payment.  The first 64484 needs no modifier but the 2nd one does since it is a duplicate code.  This is absolutely appropriate use of the 59 modifier to allow proper adjudication of the claim.  There is no reason to let a claim deny or reject before you "fix" it.  I too have coded spinal procedures for about 20 years now and I have always listed them in this fashion for all payers in many different states.  We use modifiers when we need them for clarity on the claim, not just for CCI edits.  I really hope this clarifies the issue for everyone.


----------



## coderguy1939

I disagree.  CCI edits are the point in this instance and determine the proper use and necessity of modifiers for Medicare patients.  This claim has already been rejected by Medicare so now it needs to be "fixed".  Yes, we use modifiers for clarity and for Medicare patients CCI edits determine how that clarity is applied.  In this instance the edits indicate no modifier should be necessary so a call to Medicare does not seem unreasonable to me.  My last input on this one.


----------



## mitchellde

CCI edits do not determine proper use of a modifier.  CCI edits let us know when two codes are not considered medically indiciated to be performed together as separate procedures.  Anytime documentation supports the use of a modifier we should use it.  We do not need CCI edits to tell us to use a 50 or 52 or 22.  Or if a physician does  identical lesion excisions in the same area they are not bundled but they are duplicate codes and yet we put a 59 on.  I know you have said this is you last input.  However I still maintain that to use the 59 to indicate distinct and separate procedure as in separate level in this case is exactly why the 59 modifier is there for us to use.  I apologize if anyone is the slightest bit offended by these posts it was never my intention, I was only trying to educate.  Thank You
Debra Mitchell, MSPH, CPC-H


----------



## magnolia1

I'm sorry, but I have to disagree with mitchellde.

Just because a CPT is listed twice on a claim does not indicate the use of modifier 59.
If the carrier understands CPT descriptions, the use of modifier 59 in this scenario should not be an issue.
I have never received edit when I've coded 64484 as two separate line items.


----------



## marvelh

What is the basis for "If you bill with units it is incorrect, units cannot be greater than one for this procedure."?  

The code description is "each additional" and can be billed with units of service.  In fact some payers prefer providers to report with the units of service field rather than separating the additional levels into separate line items.


----------



## mitchellde

In the 1500 billing manual it states that units cannot be greater than one unles the code comes as quantities such as drugs or timed services.  Each is not a quantity, and the rest of the code states to list separately.  Many times when using units either the payment is incorrect or a denial is issued for units out of range.  I know a lot of people bill this way however it is incorrect.


----------



## RebeccaWoodward*

Not trying to sound like a devils advocate but I do have one carrier that tosses this ideology out the window.  Our BCBS carrier requires 2 units when billing for bilateral procedures (example-20610-50).  Below is an excerpt from their billing/coding manual.......

*"Modifier -50 should be used for bilateral procedures. Bilateral procedures should be listed on the claim as a single line item, with modifier -50, and a two in the units field."*


----------



## mitchellde

Pretty humorous actually!  They should read the 1500 billing manual.  However when you have it writing from a payer then it is suposedly correct to list it their way.  Too many times I have observed that using units is the way people are taught or the billing software tells them so.  And this is what will cause unecessary underpayments and denials, that is why I teach it strictly from the 1500 instructions, then make the payer cough up something in writing.


----------



## FractalMind

I agree with Guru too, I just attended an AAPC audio-conference for pain mgmt and we should append mod-59 to the 3rd level in this code scenario per AAPC instructions, so the coding should look like this:
64483, 64484, 64484-59, 27096 and 77003-26

Erika.


----------



## mitchellde

Thank you so much, I felt like I was out there riding the wave by myself on this one!


----------



## magnolia1

Hello again....
Please refer to the CPT Assistant below. It explains why codes 64480 & 64484
were developed and should dispel the notion that modifier 59 has to be utilized when coding these procedures. As stated previously, I have coded 64484 (for multiple levels, as separate line items) to Medicare with only "anatomical" modifiers and have never been notified by our billing office as to denials for duplicate procedures.

Transforaminal Injection(s): Single vs Multiple Levels

To differentiate technique and code usage, the transforaminal epidural injection codes 64479-64484 describe both diagnostic and therapeutic nerve root injections that enter the epidural space through the intervetebral foramen requiring separate needle insertions at several unilateral spinal levels. This technique differs from interlaminar epidural injection technique (62310-62311) and the facet joint nerve injection technique (64470-64476). Fluoroscopic guidance and contrast material is used to localize the flow pattern (eg, either in the foramen and into the epidural space, or in a facial plane, or in an epidural vein). The needle is moved until contrast outlines the selected spinal nerve and flows into the foramen and then into the epidural space. Since the vertebral artery (in the cervical spine), radiculomedullary arteries, as well as the spinal cord are in close proximity to the nerve root, this procedure involves a much higher risk with more work than a translaminar epidural injection.

Depending on the treatment required, multiple spinal levels may require injection (eg, foraminal stenosis from a variety of disorders, cervical spondylosis, lumbar spinal stenosis, postoperative back and leg pain, herniated discs in the far lateral or neuroforaminal position). Previous cervical or lumbar fusions make this procedure more difficult. In the case of a previous lumbar or cervical fusion, sometimes the only way to access the injured nerve root is through the transforaminal approach.

Since there can be multiple levels of pathology, which may require more than one injection site for diagnostic and therapeutic reasons, codes 64480 and 64484 were established. When performing transforaminal epidural injections at different levels, the patient's position does not change, but a new injection at the different level is performed. Each level is a separate injection with more physician work needed. Multiplanar real-time fluoroscopic imaging is mandatory for any transforaminal injection. When a transforaminal injection is performed on the opposite side, the work may involve redraping and positioning of the patient. Therefore, when performing bilateral transforaminal epidural injections at a single spinal level, modifier 50 is appended to the appropriate code(s).



CPT Assistant © Copyright 1990–2009 American Medical Association. All Rights Reserved


----------



## marvelh

Actually I don't see in Chapter 26 - Completing and Processing Form CMS-1500 Data Set of the CMS Claims Processing Manual  where it states that 24G can not be greater than 1 except for meds and timed based services.

Here is what I found:
Item 24G - Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered. Some services require that the actual number or quantity billed be clearly indicated on the claim form (e.g., multiple ostomy or urinary supplies, medication dosages, or allergy testing procedures). When multiple services are provided, enter the actual number provided. For anesthesia, show the elapsed time (minutes) in item 24g. Convert hours into minutes and enter the total minutes required for this procedure. For instructions on submitting units for oxygen claims, see chapter 20, section 130.6 of this manual. NOTE: This field should contain at least 1 day or unit. The carrier should program their system to automatically default "1" unit when the information in this field is missing to avoid returning as unprocessable.

I have seen this field used to report multiple units of service for many different CPT & HCPCS codes and have payers adjudicate them correctly.


----------



## mitchellde

Here is the section out of the official 1500 billing guide which directly relates to the original question:
Postoperative Pain Control Procedures 
When provided principally for postoperative pain control, peripheral nerve injections and neuraxial (spinal, epidural) injections can be separately reported on the day of surgery using the appropriate CPT procedure with modifier -59 (Distinct Procedural Service) and 1 unit of service. 
Examples of such procedures include: 

62310-62319 Epidural or subarchnoid injections  
64415-64416 Brachial plexus injection, single or 
continuous 
64445-64448 Sciatic or femoral injections, single or 
continuous 
64449 Lumbar plexus injections, continuous 

These services should not be reported on the day of surgery if they constitute the surgical anesthetic technique.  

NOTE: Modifier 59 requires that the medical record substantiate that the procedure or service was a distinct or separate services performed on the same day. 

This section follows the section which talks about units in general.


----------



## mbort

ok...I'm going to throw my head on the chopping block here..

If the 2nd 64484 IS a 3rd level, then  I would code as follows 
64483, 64484, 64484-59

units would not be appropriate and nor would bilateral (50) if this is a 3rd level.

my two cents


----------



## marvelh

What "official 1500 billing guide" are you referencing?  Chapter 26 of the CMS Claims Processing Manual does not include a section on postoperative pain management procedures


----------



## marvelh

Are you referencing the ASA position paper "REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH ANESTHESIA" that was updated last September?
http://www.asahq.org/publicationsAndServices/standards/43.pdf

Note that the transforaminal epidural injection codes (64479-64484) are not included in the list.  Side note: rarely to never would transforaminal epidural injections be performed for postoperative pain control.

I have seen providers report 3 levels of transforaminal epidural injections in a multitude of methods and have most payers process them correctly, such as

64483 with 1 unit of service
64484 with 2 units of service

OR

64483 with 1 unit of service
64484 with 1 unit of service
64484 - 59 with 1 unit of service

OR

64483 with 1 unit of service
64484 with 1 unit of service
64484 - 76 with 1 unit of service

The method that is problematic with many payers is multiple line items that are identical...

64483 with 1 unit of service
64484 with 1 unit of service
64484 with 1 unit of service

The payer's claims processing software views line 2 & 3 as identical and processes the second line item as denied due to duplicate data entry.  This denial can certainly be appealed but causes delays in collections and increases the work (cost) of the billing staff.

Unfortunately, with HIPAA we didn't get payer uniformity with reporting simple things like bilateral procedures and/or multiple units of add-on codes! :>)  Just those 2 issues could most likely reduce the costs of health care but in my mind "He who has the gold, has the power to determine how they want services reported."  In essence, payers still have control of how we need to report these types of services and there isn't necessarily one size fits all or one solution that will work with all payers.  Rats, if only we had the ideal world! :>)


----------



## KHH

*Who was the instructor*

Who was the instructor for your pain managment class?


----------



## marvelh

or I found an identical excerpt from the NHIC Anesthesia Billing Guide: http://www.medicarenhic.com/providers/pubs/Anesthesia Billing Guide.pdf 

But I don't see the reference to it would be incorrect to bill in field 24G with units for services other than drugs and time based codes.  Certainly those codes in the list would most likely only be performed with a single unit of service, such as a continuous lumbar plexus infusion but that wouldn't necessarily preclude other services from being reported with multiple units of service.  In fact, the Medicare Medically Unlikely Units indicate that there are many codes that can be reported with multiple units of service up to the MUE limit.

Why I am looking for the specific reference is that just recently I looked into the issue of using 24G for reporting multiple units of service for other services for a provider and his biller & couldn't find anything that was in "black and white" that specified correctness or not.

Thanks


----------



## mitchellde

There is an actual CMS billing manual it was updated Feb 08 and that is where this information comes from, of course many people will see the same information and interpret it many different ways.  When you give two different injections at two different sites or excise two different lesions from two different areas, then these are not multiple units of the same service.  each one is unique and different, I really cannot explain it any other way.  Also when I have worked as a consultant, I have looked at numerous rejections and discovered many underpayments due to the use of units.  I know it is done, I just do not agree with it nor is it correct.


----------



## marvelh

can you provide the url link for the CMS billing manual?


----------



## coderguy1939

I have some additional comments to make about this discussion.

The question of using mod 59 with add-on codes revolved around a *Medicare* patient.

Medicare's rationale for the use of mod 59 states that the "Multiple services on one day by the same provider may appear to be incorrectly coded, when in fact the services have been performed as reported.  Because the circumstances cannot be easily identified, a modifier was established to permit claims of such a nature *to bypass correct coding edits."  

I think the general agreement is that, in this instance, there were no edits to bypass.  So CCI edits not only tell us when a modifier might be used, they also tell us when they are not necessary.

Regarding the use of LT/RT for other than anatomical specificity, the Medicare Physician's Fee Schedule database indicates that  LT/RT can be submitted with 64483, 64484 for reimbursement for bilateral procedures.

Our FI attached this information to a communication received years ago regarding how these modifiers should be used for reimbursement for bilateral and unilateral procedures.  For unilateral procedures modifiers LT or RT were to be used.

So, for our Medicare patients for the procedures being discussed, 59 would not be the appropriate modifier to attach to these codes.  As I indicated previously, we do have instances when one of these add-on codes is denied.  In those cases, we have been instructed to appeal the denial, not add mod 59.  The MLN article I referred to stresses the need to avoid using mod 59 if another established modifier is appropriate.  Our FI established the appropriate modifier.

I think it was reasonable and prudent to ask why this claim was denied and suggest that the coder contact their FI or Medicare.  The reason for denial was never revealed or discussed.  Our FI will not tell us what modifier to use, but they will often tell us if one is necessary and where to find the info on their website.

Regarding mod 59 and other carriers, we have used RT or LT for the procedures in question and are paid appropriately.  In those instances where  a claim has been billed correctly for these procedures and a denial occurs for an add-on code, if the reason for denial is unclear we contact the carrier to resolve the issue.

On a personal note, I think we all are hoping to provide useful information and insights and I think most of us come away feeling educated, but this is, after all, a blog and not a classroom.  In that regard phrases like "I hope this clarifies this for everyone" might be avoided.  It seems to imply that a definitive answer has been given and may have the effect of shutting down further discussion.  What might be useful information for one coder in one part of the country may not be for another.  In addition, as a professional courtesy, if a coder has serious concerns about another coder's input, I'd like to suggest that they contact the coder through the Private Message board to discuss the issue rather than immediately adding Disapproving Comments to the coder's profile.  I think it would be more in keeping with spirit and objectives of this forum.*


----------



## RebeccaWoodward*

Well said Coderguy~


----------



## jessieindiego

when we bill out 64483, 64484, 64484 i have never once added a modifier 59 because the 64484 is an add on code...now you also did state that there was a 27096 performed as well this is where, when i code i put the 59.

64483 Lt 
64484 Lt
64484 Lt
27096-59


Medicare is very picky as well....

What denial reason/code did medicare give you on this?

http://www.lamedicare.com/provider/datanaly/modflow/Mod59.pdf


----------

