# Need help-diff. operative session/same day



## ctown (Jul 10, 2013)

I am having trouble with Medicare (FLorida), paying the *anesthesia*, (Not surgical, ie  00320, etc) for a different operative session /same day.  The patients will have bleeding complications and come back to the OR hours later for the same or similar procedure to control bleeding/complications from inital procedure.  I have tried billing with a 59, 78 and Medicare denies and says invalid modifier. Any suggestions?? Is 59 not used on anesthesia base codes??

Also- my anesthesiologist performed a cric trach (CPT 31605) in addition to her anesthesia base and time.  How do you bill for this?  Anes base and then use a 59 on the 31605 or bill w/o 59?  Of course, the patient  has Medicare.  The surgeon was not comfortable performing the procedure , therefore the anesthesiologist performed the trach ( this was not the primary procedure however).

Any help is greatly appreciated.  I have researched these both and have come up with different answers.


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## LeslieJ (Jul 11, 2013)

*diff. operative session/same day*

*FCSO may actually be considering your 2nd claim a "repeat service".  Some payers do that, requiring modifier 76.  I would contact the payer directly to see if this is a modifier they want for anesthesia.  It's not what we learned "back in the day" for this modifier, but then, coding isn't what we learned back then, either!

The following comes from FCSO's website: *

"Preventing duplicate claim denials 

Effective July 1, 2013, new claim system edits may result in additional duplicate claim denials to your practice. Please share this information with your billing companies, vendors and clearing houses. The Centers for Medicare & Medicaid Services (CMS) has instructed Medicare contractors to enhance claim system edits to include same claim details in its history review of duplicate procedures and/or services. The edits will search within paid, finalized, pending and same claim details in history. This means that unless applicable modifiers are included in your claim, the edits will detect duplicate and repeat services within the same claim and/or based on a claim previously submitted.

To minimize a potential increase in duplicate claim denials, please review your billing software and procedures to ensure that you are billing correctly. Some services on a claim may appear to be duplicates when, in fact, they are not. Please ensure appropriate use of condition codes and/or modifiers to identify procedures and services that are not duplicates. A complete list of condition codes and modifiers can be found in the Current Procedural Terminology (CPTÂ®) codebook. The following are a few examples of modifiers that may be used, as applicable, to identify repeat or distinct procedures and services on a claim:

• Modifier 76 may be used to indicate a repeat procedure or service by the same provider, subsequent to the original procedure or service. 

• Modifier 91 may be used to indicate repeat clinical diagnostic laboratory tests.  This modifier is added only when additional test results are medically necessary on the same day. 

• Modifier 59 may be used, as applicable, to identify procedures or services that are normally reported together but are appropriate to be billed separately under certain circumstances. Modifier 59 indicates a procedure or service by the same provider, distinct or independent from other services, performed on the same day. 

Note: Procedures, services and modifiers submitted on your claim should be supported by documentation in the patient's medical record. 

Sources: CMS MLN MattersÂ® MM8121 external pdf file, CMS Internet-only manual (IOM), Publication 100-04, chapter 1, Section 120-Detection of duplicate claims external pdf file, and the American Medical Association's (AMA) 2013 Current Procedural Terminology (CPTÂ®) codebook."

*As for the trach, I would code out using modifier 59 on that service.  You may need to do an appeal if this gets denied, but if the documentation shows that it was at the request of the surgeon and separate from anesthesia services, it should get paid.

Good luck!   L J*


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## ctown (Jul 12, 2013)

Thanks so much!


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## LaVoncye (Jul 18, 2013)

Hello are you using your physician status modifier in addition to your established modifier ex. 78 for the return to the operating room for the complication. Some carriers want both.


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