jveronick
New
Julie Veronick
13 mins
Need some help on a revision hip billing for Humana/Medicare Advantage.
In the opt note, surgeon states (after getting down to the component needing replaced - a left total hip):
"Wide exposure was achieved and the hip dislocated posteriorly. The modular femoral head was removed with a lap on the posterior most aspect of the head. The synovium was debrided and the taper cleaned and dried. The new ceramic Delta Option head was impacted onto the taper with three progressively harder blows and the hip was then reduced without marring the ceramic head." He then goes on to note ORIF of a periprosthetic fx and then closure of the wounds.
We received correspondence from Humana-after they asked for medical records-that states:
"27183, LT, X4: The medical record indicates reduced services were performed during the revision of total hip arthroplasty; femoral component. The appropriate modifier was omitted from the claim."
As you can see, we billed 27138, LT, X4 - which is specifically for revision THA of the femoral component only - which is exactly what the surgeon dictated. We also billed for the ORIF of the periprosthetic fracture - they did pay for that one fully.
Any ideas why they would say these are reduced services? Humana/Medicare Advantage is the only insurance we've had this problem with so far. I've received some feedback online that says we should've used mod -52 for reduced services because he didn't do anything with the stem. Is that your opinion as well?
13 mins
Need some help on a revision hip billing for Humana/Medicare Advantage.
In the opt note, surgeon states (after getting down to the component needing replaced - a left total hip):
"Wide exposure was achieved and the hip dislocated posteriorly. The modular femoral head was removed with a lap on the posterior most aspect of the head. The synovium was debrided and the taper cleaned and dried. The new ceramic Delta Option head was impacted onto the taper with three progressively harder blows and the hip was then reduced without marring the ceramic head." He then goes on to note ORIF of a periprosthetic fx and then closure of the wounds.
We received correspondence from Humana-after they asked for medical records-that states:
"27183, LT, X4: The medical record indicates reduced services were performed during the revision of total hip arthroplasty; femoral component. The appropriate modifier was omitted from the claim."
As you can see, we billed 27138, LT, X4 - which is specifically for revision THA of the femoral component only - which is exactly what the surgeon dictated. We also billed for the ORIF of the periprosthetic fracture - they did pay for that one fully.
Any ideas why they would say these are reduced services? Humana/Medicare Advantage is the only insurance we've had this problem with so far. I've received some feedback online that says we should've used mod -52 for reduced services because he didn't do anything with the stem. Is that your opinion as well?
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