# 99152 and 99153 - Denial with Anthem BCBS



## shruthi (Apr 13, 2017)

We are facing issues with Conscious sedation codes 99152 and 99153. Whenever we bill these conscious sedation codes in conjunction with colonoscopy codes, Anthem BCBS and UHC insurance are denying 99152 and 99153 stating it is bundled with colonoscopy codes (45378, 45385, 45380).
As per CCI edits modifiers are not required.

Anyone else facing the same problem?

Kindly share your thoughts and suggestions to overcome this issue.

Regards,
Shruthi.


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## terrid00 (Dec 1, 2017)

This has become an issue for us as well, I don't think BCBS are following the codes; maybe they dont know it changed; but if they want a modifier use it; but they should be paying for it since it is NOT inclusive in the codes anymore.


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## strader (Jan 1, 2018)

*Major Payors editing 99152 for GI codes*



terrid00 said:


> This has become an issue for us as well, I don't think BCBS are following the codes; maybe they dont know it changed; but if they want a modifier use it; but they should be paying for it since it is NOT inclusive in the codes anymore.



We have multiple major payors editing 99152 for GI codes.  I checked the NCCI tables and on 7/1/17, Medicare added 99152 as an edit to multiple GI codes:
CPT only copyright 2016 American Medical Association.  All rights reserved.						
Colum1/Column2 Edits						
Column 1	Column 2	*=in existence	Effective	Deletion	Modifier	PTP Edit Rationale
		prior to 1996	Date	Date	0=not allowed	
				*=no data	1=allowed	
					9=not applicable	


45378	99152		20170701	*	1	CPT Manual or CMS manual coding instructions

My understanding of this is that Medicare NCCI edits apply to Medicare only and this is correct for CMS because they require HCPCS code G0500 when moderate conscious sedation is performed with a GI procedure.  For Medicare patients the provider will just need to crosswalk 99152 to G0500.

Commercial payors have adopted the NCCI edits but do not allow G0500, so the McKesson claim editors I checked are requiring a modifier to override the edit.  

Is this what others are seeing?  

Since the separation of the sedation from the codes it used to be bundled into in January, 2017, CPT instructs providers to bill 99152 and there are no modifiers mentioned in the guidelines.  The only available modifier is 59 to override the edit.  This seems wrong for commercial payors to use CMS manual coding instructions without allowing use of G0500 we're forced to use 59.

Has anyone seen anything published about this situation?  It's already challenging to bill a colonoscopy without this complication.


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## CodingKing (Jan 1, 2018)

strader said:


> We have multiple major payors editing 99152 for GI codes.  I checked the NCCI tables and on 7/1/17, Medicare added 99152 as an edit to multiple GI codes:
> CPT only copyright 2016 American Medical Association.  All rights reserved.
> Colum1/Column2 Edits
> Column 1    Column 2    *=in existence    Effective    Deletion    Modifier    PTP Edit Rationale
> ...



Most commercial carriers follow NCCI with some with custom edits. Blue Cross of Massachusetts for example started accepting G0500 eff 9/1/17, prior to that they followed 2016 guidelines where moderate sedation bundled.

https://provider.bluecrossma.com/Pr...stroenterology_payment_policy.pdf?MOD=AJPERES



> Not reimbursed when reported with a code in the former Appendix G of the 2016 CPT manual. No modifier override from 01/01/2017 through 08/31/2017.


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## bford27 (Jan 18, 2018)

strader said:


> We have multiple major payors editing 99152 for GI codes.  I checked the NCCI tables and on 7/1/17, Medicare added 99152 as an edit to multiple GI codes:
> CPT only copyright 2016 American Medical Association.  All rights reserved.
> Colum1/Column2 Edits
> Column 1	Column 2	*=in existence	Effective	Deletion	Modifier	PTP Edit Rationale
> ...




Have you found any more information on this?  We are also having this issue with all commercial payers.  A couple will accept G0500 (Kaiser and Premera, for example), but many others will not.  The 07/01/2017 NCCI edit update now shows that a modifier 59 is required, if appropriate, on the 99152 if billing with the colonoscopy, but that does seem wrong to indicate that it is a separate service.  However, I did notice that the Appendix G stating that 99152 was a component of the colonoscopy codes was removed from the code books, so my question becomes, does this mean it is no longer a component?  And if so, why have the edits phrasing not also been updated to show that 99152 is no longer a component of those codes?  Do we or don't we add a 59 modifier to the 99152 when billing it with a colonoscopy code like 45380??


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## kbanter (Jan 19, 2018)

This may be helpful
https://www.cgsmedicare.com/parta/pubs/news/2017/03/cope2489.html


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## bford27 (Jan 19, 2018)

kbanter said:


> This may be helpful
> https://www.cgsmedicare.com/parta/pubs/news/2017/03/cope2489.html



Unfortunately that was posted prior to the NCCI edit update 07/01/2017.  I'm still confused based on the elimination of Appendix G and the fact that the colonoscopy codes don't indicate moderate sedation is a component, so why would it be billed that way?  I don't to add a 59 just for the sake of it, but it isn't clear if you have to now.


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## cicelyd (Feb 2, 2018)

*45378, 99152*

The CCI edits are flagging the 99152 as well for us when billed with CPT 45378.  We were given certain modifiers to use through VitalWare and the code we have been using was the XU modifier on the 99152.  If someone is using something different or not using anything and still are getting paid, please let me know.   I would really like to get help on this issue as well.


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