# When McKesson edits contradict commercial insurance AND CMS guidelines



## ollielooya (Jul 28, 2011)

Ok, how does one go about resolving issues when a claim is denied for incorrect surgery-modifier combination when using -50 with 64612?  I verified it as assignable with MCR status indicators and also with the major carrier who is refusing payment whose own policy states that it is allowed.  Provider Relations basically said they can't help and recommended we file an appeal with supportive documentation.  Yikes!  I pulled up documentation to that effect and sent it certified mail.  I tried "playing" with the McKesson edits at the website and there is no conceivable way to get it to accept a bilateral modifier.  So, basically it looks like 1) we bill without modifier and accept the payment, 2) bill with modifier 50 and receive the rejection to 3) followup with claim action request, and if that doesnt' resolve the issue.......4) appeal...and then what?   Perhaps the code descriptor is what triggers the edit by AMA standards?   Just not sure.

Is there an alternative fix to  this messy issue? Any input from those of you who may have encountered a similar situation with the editis even if it regards a different code?  

---Suzanne E. Byrum CPC


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## lavanyamohan (Jul 29, 2011)

Hello,

A piece of information from Internet; I hope this helps - 

Medicare payers will allow reimbursement for a single unit of 64612 per site. For example, if the neurologist uses Botox to treat blepharospasm with injections into the skin around both eyes, you would use 64612 with modifier -LT (Left side) on the first line of the CMS-1500 form and 64612-51-RT (Multiple procedures; Right side) on the second line to show that you have performed the procedure bilaterally. However, if the neurologist administered more than one injection on the same side, you may still only report a single unit of 64612;

Since, I don't have a new thread option I am asking one question here: 
I am looking forward to work from home as a coding consultant;
How am I to post this information in the forum to enable many persons respond?

Thanks and Regards,
LMohan


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## ollielooya (Jul 29, 2011)

Thank you so much for your response.  Unfortunately, the edits will block and not allow the use of modifier 50, and that's my point.  We're instructed by policy and guidelines to do it this way, but the edits bounce it from Colorado to the Pacific Ocean.  Hopefully our appeal with policy/documentation proof will over-ride but from what I've learned from Provider Relations and others, this is highly unlikely.  That is why I submitted the original question.

Now you can post your question in the general category (all things coding), but you might want to do a search in the archives first to see the response to similar questions such as yours.  Once you dig around in the forums you might find the best place suited to fit your request.  Questions such as yours appear quite frequently, so it should be easy to pull up.  I work from home, but my situation in acquiring this position is not the normal route most are required to take. (which is too long for this thread.)

---Suzanne E. Byrum  CPC
    Everett, WA


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## rmelissa (Nov 29, 2011)

Hello, I'm hoping I might be able to shed some light on this one. In the state of CT, the LCD article states that you can't use the bilateral modifier for 64612. Here is a link:

http://www.cms.gov/medicare-coverag...es,+Inc.+(13102,+MAC+-+Part+B)&s=9&IsPopup=y&

If that link doesn't work, I found it under article: A46164.


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## mitchellde (Nov 29, 2011)

ollielooya said:


> Thank you so much for your response.  Unfortunately, the edits will block and not allow the use of modifier 50, and that's my point.  We're instructed by policy and guidelines to do it this way, but the edits bounce it from Colorado to the Pacific Ocean.  Hopefully our appeal with policy/documentation proof will over-ride but from what I've learned from Provider Relations and others, this is highly unlikely.  That is why I submitted the original question.
> 
> Now you can post your question in the general category (all things coding), but you might want to do a search in the archives first to see the response to similar questions such as yours.  Once you dig around in the forums you might find the best place suited to fit your request.  Questions such as yours appear quite frequently, so it should be easy to pull up.  I work from home, but my situation in acquiring this position is not the normal route most are required to take. (which is too long for this thread.)
> 
> ...


I agree you should be able to use the 50 but it is also acceptable to use 2 lines with an RT on one line and an LT on the other and not use the 50 at all.   Are you saying your software will not allow this either?


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## mitchellde (Nov 29, 2011)

ollielooya said:


> Ok, how does one go about resolving issues when a claim is denied for incorrect surgery-modifier combination when using -50 with 64612?  I verified it as assignable with MCR status indicators and also with the major carrier who is refusing payment whose own policy states that it is allowed.  Provider Relations basically said they can't help and recommended we file an appeal with supportive documentation.  Yikes!  I pulled up documentation to that effect and sent it certified mail.  I tried "playing" with the McKesson edits at the website and there is no conceivable way to get it to accept a bilateral modifier.  So, basically it looks like 1) we bill without modifier and accept the payment, 2) bill with modifier 50 and receive the rejection to 3) followup with claim action request, and if that doesnt' resolve the issue.......4) appeal...and then what?   Perhaps the code descriptor is what triggers the edit by AMA standards?   Just not sure.
> 
> Is there an alternative fix to  this messy issue? Any input from those of you who may have encountered a similar situation with the editis even if it regards a different code?
> 
> ---Suzanne E. Byrum CPC


Suzanne can I ask exactly what was injected in other wrods what does the procedure note state, I have a thought here and it is a good one but iI want to know what the note says first.


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## ollielooya (Nov 29, 2011)

I'm so pleased to see some responses to my earlier thread  posted 3 months ago. Thank you!  Still dealing with this issue.  Debra, our software has no issues with sending out separate line services with modifer 50 OR 2 lines with RT and LT.  It's just that the insurance company will not accept it, and use the CPT Assistant rules in denying, despite what MCR allows and their own regional policy.  So, it doesn't matter at all what the other insurance companies allow whether they be commercial or governmental, they WILL not process this code for bilateral charges,  You asked about what was being injected, here's an extraction:  ( Botox (J0585) is being administered for spasmodic torticollis  at the physician'soffice).  Patient was consented for injection of Botox.  The risks of the procedure were explained to her.  The following muscles were injected: 

Procerus one injection, 5 units 

Corrugator 2 injections on each side, each injection 5 units  

Frontalis 5 injections on each side, each injections 5 units  

Temporalis 3 injections on each side, one injection 10 units and two injections 7.5 units each 

Occipitalis one injection on each side, each injection 10 units

What is your idea?  I can hardly wait to hear whether it's favorable or not!

---Suzanne E. Byrum CPC


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## ajs (Nov 30, 2011)

ollielooya said:


> I'm so pleased to see some responses to my earlier thread  posted 3 months ago. Thank you!  Still dealing with this issue.  Debra, our software has no issues with sending out separate line services with modifer 50 OR 2 lines with RT and LT.  It's just that the insurance company will not accept it, and use the CPT Assistant rules in denying, despite what MCR allows and their own regional policy.  So, it doesn't matter at all what the other insurance companies allow whether they be commercial or governmental, they WILL not process this code for bilateral charges,  You asked about what was being injected, here's an extraction:  ( Botox (J0585) is being administered for spasmodic torticollis  at the physician'soffice).  Patient was consented for injection of Botox.  The risks of the procedure were explained to her.  The following muscles were injected:
> 
> Procerus one injection, 5 units
> 
> ...



This might be the type of claim that needs the assistance of the physician.  Your physician can request to speak to the medical director for that plan.  Sometimes when you get physician to physician appeals you can get an override of the built in edits.  Check the appeals process and see how you go about getting all the way to the top.


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## mdoyle53 (Nov 30, 2011)

In these situations, I have found that the MD talking with the Medical Director of the insurance company usually gets it paid immediately.  Just make sure to provide the MD with the information necessary for the discussion and perhaps be in the room or on a conference call with the physician.  An MD appealing directly has almost always worked in my experience.

Remember the insurance carrier personnel have a script and do not know what to do beyond that so appeal is usually the way to get around it.


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## ollielooya (Nov 30, 2011)

These are great helps everyone, thank you!  The only drawback is that there are so many of these type of claims it looks like this would be an ongoing issue.  Could we turn this into a contractual issue?  And since the doctor is expanding his practice into performing more of these types of treatment, we'd like to be well armed and fortified for dealing with carrier issues.  But for the time being going to explore your suggestions!  ---Suzanne


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## RonMcK3 (Nov 30, 2011)

Would it help for your MD ask their MD for a written directive on how future procedures of this type are to be coded and documented when you submit them?


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## ajs (Dec 1, 2011)

RonMcK3 said:


> Would it help for your MD ask their MD for a written directive on how future procedures of this type are to be coded and documented when you submit them?



No because payers typically will not tell you how to bill to get paid.  We have to just code correctly and then work thru the systems of edits that are in place.


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## ajs (Dec 1, 2011)

ollielooya said:


> These are great helps everyone, thank you!  The only drawback is that there are so many of these type of claims it looks like this would be an ongoing issue.  Could we turn this into a contractual issue?  And since the doctor is expanding his practice into performing more of these types of treatment, we'd like to be well armed and fortified for dealing with carrier issues.  But for the time being going to explore your suggestions!  ---Suzanne



If you have a lot of this type of issue going before the medical director at a plan, chances are there will be changes made in the future.  But you can address this issue when contracting with a carrier.


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## ollielooya (Dec 1, 2011)

This was helpful reading, however this particular LCD seems to indicate that modifier 50 is acceptable.  At least that's how I interpret it.  ---Suzanne


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## ajs (Dec 1, 2011)

ollielooya said:


> This was helpful reading, however this particular LCD seems to indicate that modifier 50 is acceptable.  At least that's how I interpret it.  ---Suzanne



Yep, under the CMS guidelines the 50 modifier is allowed to indicate bilateral on that procedure code.  Unfortunately, McKesson does not have to follow the CMS guidelines, they can set up their own edits.  But when it comes to appealing claims we can sure use the CMS guidelines as a standard of care.  Hopefully the McKesson edits do allow the RT and LT modifiers instead.


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## ollielooya (Dec 1, 2011)

Arlene, thank you for your continual help.  I tried emailing you privately thru the forum a while back but not even sure you got my message.  Unfortunately with this particular insurance company RT and LT are not recognized for payment utilizing two separate lines, for this CPT code, so you can see the ongoing dilemna.  I'm so thankful this thread is staying alive as it's been such a useful tool from which to base the next move.  Hopefully, Debra Mitchell will report in as I've been wating to see what she has found out.   ---Suzanne


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## ajs (Dec 1, 2011)

ollielooya said:


> Arlene, thank you for your continual help.  I tried emailing you privately thru the forum a while back but not even sure you got my message.  Unfortunately with this particular insurance company RT and LT are not recognized for payment utilizing two separate lines, for this CPT code, so you can see the ongoing dilemna.  I'm so thankful this thread is staying alive as it's been such a useful tool from which to base the next move.  Hopefully, Debra Mitchell will report in as I've been wating to see what she has found out.   ---Suzanne



Which carrier are you dealing with?  Sorry I don't think I got your message before but you can email me directly at smith_arlene@hotmail.com.  I check my junk mail all the time to be sure I don't miss messages that might be coding related.


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## mitchellde (Dec 1, 2011)

ollielooya said:


> Arlene, thank you for your continual help.  I tried emailing you privately thru the forum a while back but not even sure you got my message.  Unfortunately with this particular insurance company RT and LT are not recognized for payment utilizing two separate lines, for this CPT code, so you can see the ongoing dilemna.  I'm so thankful this thread is staying alive as it's been such a useful tool from which to base the next move.  Hopefully, Debra Mitchell will report in as I've been wating to see what she has found out.   ---Suzanne



Hang tight I have had some other stuff to deal with but I am close to an answer it may not be what we all want but an answer nonetheless I hope.


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## losborn (Dec 2, 2011)

While awaiting The Answer form Debra (;-)  I thought I'd add my two cents.

I have know quite a few Medical Directors - and it will really depend on them.  Some are very understanding and really want to pay the doctor what they deserve (but not a penny more), while others stick to the Letter of the Law and will not budge.  I knew one who reveled in his nickname:  The Terminator (for teminating so many providers from the plan).

Good Luck!

Lin
CPC, CEMC, CPMA


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## ollielooya (Dec 2, 2011)

*appreciating all the forum input from my colleagues*

Yes, while I'm taking notes and waiting, perhaps another colleague who writes for our Coding Edge magazine, Marvel Hammer might comment.  At least I can hope.  I think a peer-to-peer review would be a good idea, although I'm sure the provider won't be pleased in having to take up those administrative duties, but if he wants to get paid......
I'm still awaiting word from the Regional Reps as how to handle this situation,....Could it be that they might not know the answer?  ---Suzanne


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## FTessaBartels (Dec 2, 2011)

*An anecdote re peer-to-peer*

Many years ago I worked on a claim where the physician performed and billed 21138 (along with other codes) for a baby with severe congenital skull deformity.

Insurance denied as "cosmetic surgery" (despite a pre-authorization).  I appealed with op note.

Insurance denied again - "cosmetic."  I asked for second level appeal, again sending op note, *photos* and another letter explaining why this was hardly "cosmetic" in nature given the several congenital deformity.

Insurance denied again - "cosmetic."  I told doc he needed to request peer-to-peer review.
He wrote a succinct note requesting a peer-to-peer review, appending the op note yet another time.  His note read, "repairing a defect in the skull to protect the brain is NOT cosmetic surgery."  

He finally got paid (about 18 months AFTER the surgery).

Never give up!

F Tessa Bartels, CPC, CEMC


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## ajs (Dec 2, 2011)

FTessaBartels said:


> Many years ago I worked on a claim where the physician performed and billed 21138 (along with other codes) for a baby with severe congenital skull deformity.
> 
> Insurance denied as "cosmetic surgery" (despite a pre-authorization).  I appealed with op note.
> 
> ...



Just makes you go...hmmmmmmm...........lol!  Good story!


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## ollielooya (Dec 6, 2011)

Just in case anyone is still interested.  FINALLY found a rep (after requesting the services of others and getting no where), who is taking this issue farther up the food chain to McKesson itself, and hopefully will get an answer soon.  Debra, if you're still 'out there" am still anxiously awaiting your response and this is my attempt to keep the thread open.  Has anyone ever fought the McKesson edits and won?
---Suzanne E. Byrum CPC


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