# Modifier needed on debridements for Medicaid payor



## abrintle (Oct 4, 2017)

Hi, I am hoping someone may be able to provide some insight. I code for a huge company that has outpatient facilities all across the Unites States. Across the boards (doesn't seem to matter the state) we have been receiving denials from Medicaid stating a modifier is needed on the procedure. It doesn't seem to matter if Medicare is primary and pays or if it is Medicaid as the primary and sole payor. The procedures we are billing are debridements (ex.  11042, 97597, etc.) It is not an heirachy issue (ex. billing 11042 & 97597 together)...the denials are simply just when one debridement is being billed. We are thinking it could be LT or RT so have sent a few claims out with that hoping that is the fix, but in case that doesn't work (don't have high hopes that it will) I was hoping someone here might know what it could be?? Medicaid will pay the E/M but not the procedure. Any help is greatly appreciated. Thank you!!


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## jingle (Oct 4, 2017)

abrintle said:


> Hi, I am hoping someone may be able to provide some insight. I code for a huge company that has outpatient facilities all across the Unites States. Across the boards (doesn't seem to matter the state) we have been receiving denials from Medicaid stating a modifier is needed on the procedure. It doesn't seem to matter if Medicare is primary and pays or if it is Medicaid as the primary and sole payor. The procedures we are billing are debridements (ex.  11042, 97597, etc.) It is not an heirachy issue (ex. billing 11042 & 97597 together)...the denials are simply just when one debridement is being billed. We are thinking it could be LT or RT so have sent a few claims out with that hoping that is the fix, but in case that doesn't work (don't have high hopes that it will) I was hoping someone here might know what it could be?? Medicaid will pay the E/M but not the procedure. Any help is greatly appreciated. Thank you!!






May I ask you what diagnosis you are using on the claims? I have not ran into a problem with Medicaid with these CPTs but normally the diagnosis codes specify LT or RT so you would not need a LT or RT Modifier. are you billing a E/M code with this Debridement? I know Medicaid does not allow that. If you could give me a little more info I would love to help if I could!


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## abrintle (Oct 4, 2017)

jingle said:


> May I ask you what diagnosis you are using on the claims? I have not ran into a problem with Medicaid with these CPTs but normally the diagnosis codes specify LT or RT so you would not need a LT or RT Modifier. are you billing a E/M code with this Debridement? I know Medicaid does not allow that. If you could give me a little more info I would love to help if I could!



Our DX's vary based on patient but typically it is in the L97 category for an ulcer with an etiology like Diabetes or Venous hypertension, etc. Our DX's are specific based on laterality and depth of wound so I completely get what you are saying. We were just trying LT/RT b/c nothing else seems to work. Not all of the claims have an E/M but the ones that do have a 25 modifier appended to the E/M w/ a separately identifiable reason for the E/M being billed separately from a debridement of the wound. And Medicaid is paying the E/Ms. Hope that helps! Thanks so much for your help! : )


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## espressoguy (Oct 4, 2017)

In the state of Washington if 97597 was done by a physician, Medicaid wants an AF modifier used. I can't speak for any other state's Medicaid policies.

97597 is a "sometimes therapy" code, meaning that this procedure can be performed by a physical therapist. Medicaid limits the number of therapy visits a patient can receive during the year. When done by a physician, there is no limit to the use of 97597. The AF modifier is for "specialty physician" and indicates that the therapy benefits don't apply.

I no longer code podiatry or wound care but I don't believe this has changed in the past couple of months. 

Also, laterality is irrelevant so LT/RT/50 is not appropriate.


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## abrintle (Oct 4, 2017)

espressoguy said:


> In the state of Washington if 97597 was done by a physician, Medicaid wants an AF modifier used. I can't speak for any other state's Medicaid policies.
> 
> 97597 is a "sometimes therapy" code, meaning that this procedure can be performed by a physical therapist. Medicaid limits the number of therapy visits a patient can receive during the year. When done by a physician, there is no limit to the use of 97597. The AF modifier is for "specialty physician" and indicates that the therapy benefits don't apply.
> 
> ...



Thank you for your help! Will do some research on that for other states and see if it may apply!! : )


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## espressoguy (Oct 4, 2017)

I forgot to mention that this doesn't apply to the 1104x debridement codes. You might check governing LCDs in the event that the state in question is following CMS guidelines.


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## abrintle (Dec 15, 2017)

espressoguy said:


> In the state of Washington if 97597 was done by a physician, Medicaid wants an AF modifier used. I can't speak for any other state's Medicaid policies.
> 
> 97597 is a "sometimes therapy" code, meaning that this procedure can be performed by a physical therapist. Medicaid limits the number of therapy visits a patient can receive during the year. When done by a physician, there is no limit to the use of 97597. The AF modifier is for "specialty physician" and indicates that the therapy benefits don't apply.
> 
> ...



I just wanted to thank you! The AF worked on the 97597s  : ) for the state of Washington. Doesn't fix all of our issues but it did help out with a significant number. Thank you!!


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## espressoguy (Dec 15, 2017)

Glad I could help. Podiatry was my first coding assignment and it took us about 9 months to get this solved. Also, if you work for a hospital and having problems getting the facility charges for 97597 paid, you are probably using the wrong rev code.


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## abrintle (Dec 15, 2017)

espressoguy said:


> Glad I could help. Podiatry was my first coding assignment and it took us about 9 months to get this solved. Also, if you work for a hospital and having problems getting the facility charges for 97597 paid, you are probably using the wrong rev code.



We are billing on the physician side. Thanks again! : )


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## erjones147 (Dec 18, 2017)

My facility doesn't bill Nevada Medicaid FFS, but I had to add the appropriate laterality or specific toe modifier to get podiatry debridement paid by Medicare

11042 is now a great payer for us and never seems to deny any more


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