# BCBS of Florida



## tpontillo (Apr 13, 2011)

I work for a GI group and we are getting denied for our multiple endoscopies.  We would bill for two egd's and bc will pay for only one.  Is anyone else having this problem?  I have been leaving messages for our provider rep but she is not returning my calls.  I have appealed these claims and they are still getting denied.  Any help with this would be appreciated.  The facility that we do the procedures are getting paid for both procedures.

Teresa


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## rcerro (Apr 13, 2011)

Did you try the repeat procedure by the same physician on the same day modifier -76.  I have never been it your particular position, but I have been in similar ones.  Separate the codes onto 2 lines and put the 76 on the second (if it applies).  If that doesn't work maybe try the same set up with -59 (if it applies).


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## MMAYCOCK (Apr 13, 2011)

*Multiple scopes*



tpontillo said:


> I work for a GI group and we are getting denied for our multiple endoscopies.  We would bill for two egd's and bc will pay for only one.  Is anyone else having this problem?  I have been leaving messages for our provider rep but she is not returning my calls.  I have appealed these claims and they are still getting denied.  Any help with this would be appreciated.  The facility that we do the procedures are getting paid for both procedures.
> 
> Teresa


BCBS just keeps changing the rules, so they have their own formula for paying multiple scopes here. If you are not attaching modifier 59, their system will probably bundle them. If you do attach modifier 59, it is at least something you have when you call for appeal. 

If you can't reach your rep, I would say start filing the complaints with your state insurance commission. That will get them to answer you more quickly than anything you can do on your own.


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## mitchellde (Apr 13, 2011)

what are the circumstances for the 2 EGDs on the same day.  You cannot throw on a modifier without knowing if it is correct.   So what 2 are you listing and what does the denial state?


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## MMAYCOCK (Apr 13, 2011)

*Mult scopes*



mitchellde said:


> what are the circumstances for the 2 EGDs on the same day.  You cannot throw on a modifier without knowing if it is correct.   So what 2 are you listing and what does the denial state?



What M says is true - I made the assumption that, like so many colo rectal procedures, more than one method was used which so often results in multiple scope codes. but by all means, don't just go throwing on modifiers assuming they're right!


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## tpontillo (Apr 13, 2011)

The egd's are one with biopsy and one with dilation.  The codes are 43249 and 43239 with a 59 modifier on one of them, I cant remember which one since I am at home right now.  They are done in separate areas.  The biopsy is usually done for gastritis or checking for h-pylori and the dilation is for esophageal obstruction, shatzis ring or dysphagia. I know this is correct coding.  The other insurance companies are paying.  Even if the other insurance deny the claim, I appeal and then get paid.  Bc is just refusing to pay.  They are saying that they are going by their rules for multiple procedures.  The rules as I understand them state they pay 100% for the first procedure and then the pay the difference from the base code and the second procedure, which means we should be paid something for the second procedure.


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## MMAYCOCK (Apr 13, 2011)

*Multiple scopes*



tpontillo said:


> The egd's are one with biopsy and one with dilation.  The codes are 43249 and 43239 with a 59 modifier on one of them, I cant remember which one since I am at home right now.  They are done in separate areas.  The biopsy is usually done for gastritis or checking for h-pylori and the dilation is for esophageal obstruction, shatzis ring or dysphagia. I know this is correct coding.  The other insurance companies are paying.  Even if the other insurance deny the claim, I appeal and then get paid.  Bc is just refusing to pay.  They are saying that they are going by their rules for multiple procedures.  The rules as I understand them state they pay 100% for the first procedure and then the pay the difference from the base code and the second procedure, which means we should be paid something for the second procedure.



There are codes for dilation that do not include a biopsy, but if you find that both are coded correctly, just FYI:
The AMA sued BCBS for adjusting their system to ignore positive payment modifiers. They settled the claim and BCBS agreed to acknowledge them until the settlement period ended. It ended and now they're back to the same old tricks. When this happened here, I followed the appeals steps and started complaining to the liason and asked the AMA for help. Check the AMA website. They have a section to help with issues like this.


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## tpontillo (Apr 13, 2011)

Thank you I didnt know about the AMA helping in this situation.  I am going to look into this


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## Peter Davidyock (Apr 14, 2011)

Blue Cross has become a serious problem everywhere. 
They are, like you said, making it up as they go. Or so it would seem.
The aforementioned AMA lawsuit is one example. Horizon BC just lost a lawsuit where they were delaying their secondary payments behind medicare claiming that they were waiting for the eobs from the primary.
Here in SC they have taken the stance that although someone will submit a letter of creditable coverage for the purpose of removing an existing condition clause they feel that they can pick and choose which conditions they will remove. I have actually had experience with that one. A pt has suffered a lifelong back issue. He moved to BC this yr and they began denying his back treatment. He submitted the letter and BC accepted it and removed his exclusions. BUT, they said they would only remove the exclusions for any "NEW" problems that they might learn about. Not the ones they already knew about.
Go figure.
I know in FLA that they require bilat procedures to be submitted first line w/o a -50 mod and then second line with the -50 mod.

One of two things are happening with them I feel. Either they are trying to align themselves as a sole governing body not accountable to anyone or they are imploding.

It's interesting to watch but it's nearly impossible to deal with.


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