# 99153 moderate sedation add on code denials for modifier



## Melissa Harris CPC (Jan 27, 2017)

Hello,

My medicare carrier (NGS JK) is denying the 99153 stating it is missing a modifier.  

Is anyone else running into this?  And does anyone know if this should be billed with a modifier and what it would be?

Thank you

Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management


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## cgaston (Jan 27, 2017)

It looks like Medicare has incorrectly bundled these codes into 17 surgical codes and 16 category III codes. I found this out on the web and it has a list of the effected codes:

https://www.acr.org/~/media/ACR/Doc...derate-Sedation-Code-Edit-Deletions.pdf?la=en

from the attached:
_
These errors will be corrected in the April 1, 2017 versions of PTP edits. At this time it has not been
determined whether a workaround can be implemented for Medicare or any of the state Medicaid
programs. Practitioners may consider delaying submission of claims for CPT codes 99151-99153
when performed with one of the listed surgical or Category III codes until the new versions of NCCI
PTP edits are implemented April 1, 2017. Alternatively if a practitioner does submit a claim including
one of the listed surgical or category III CPT codes and one of the CPT codes 99151-99153 for the
same date of service and the CPT code in the range 99151-99153 is denied, the denial may be appealed
on or after April 1, 2017._

Hope it helps!


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## Melissa Harris CPC (Jan 27, 2017)

Thank you so much!!
Melissa


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## chrysel (Feb 1, 2017)

*Medicare denial for CPT 99152*

Medicare is denying CPT 99152 stating CO 5 which is "procedure code inconsistent with POS" and then M77 which is for either invalid or missing modifier. It was billed as POS 11 and TOS 1. Any suggestions on how this needs to be sent. Any help is appreciated.

Thanks
Chrysel


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## stogsmom3 (Dec 13, 2017)

*99152 moderate sedation denials for modifier*

I've been recieving denials from commercial payors requiring a modifier for 99152 with endoscopy procedures.  Does anyone know if its required?

Thanks
Melissa


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## tfischer (Jan 5, 2018)

*Denials on 99152 by Commerical Payors on GI Endoscopic procedures*



stogsmom3 said:


> I've been recieving denials from commercial payors requiring a modifier for 99152 with endoscopy procedures.  Does anyone know if its required?
> 
> Thanks
> Melissa



I have also been receiving denials from several commercial payors on 99152 when billing with GI Endoscopic procedures. Payors are stating it's bundled with primary procedure, but I was of the understanding the MCS part of the procedure was pulled out of the primary procedure value as of January 1, 2017. Has anyone else been experiencing denials on 99152 with GI procedures? If so, have you had an luck with resolving?


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## missyah20 (Jan 30, 2018)

Tiffany - I would try sending appeals on your 99152 denials.  As long as your documentation supports I would note that as of 1/1/17 moderate sedation was no longer included in the 45378 (or whatever surgical code you are billing) and should be separately reimbursable.


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