Wiki 45380 unpayable with 45385

[ksiegler]

I have received a few denials of payment from insurance companies stating that 45380 is unpayable with 45385 even though I've put a modifier 59 on the second CPT code (45380). I don't see that there's an issue according to my Coding Companion or with mutually exclusive codes. I had always been able to get paid before so it strikes me as odd that all of a sudden I'm not getting this paid. ???

Has anyone else had the same issue or have any ideas as to why I wouldn't be able to get paid for this?

 

[urbanbutter]

45380 & 45385

Try appending modifier 59, 51 to code 45385. It would also help if you're able to add notes to indicate what portion of the colon the procedure was performed. I always do that and my providers are great about indicating the exact location so that makes my job a little easier.The more you document you increase your reimbursement potential. Good luck

 

[cingram]

you only need a -59. go on the medicare website and look up Endoscopy Families. I get this denied all the time then I call the insurance and tell them about that document and it gets paid everytime.

https://www.noridianmedicare.com/sh...oscopy_Families_and_Payment_Rules_Updated.htm

 

[bdobyns]

We have had this problem with a few payers in the past, and the solution was pretty simple. Unfortunately it does require an appeal letter indicating that separate techniques were used on separate lesions. Include the op note in your appeal. Once you have appealed this 3 times successfully they will generally get the idea and update your profile. Appeals are costly for the insurance company, once you establish a pattern that you are correct and will fight for your proper reimbursement you will not receive that denial reason again. If you continue to get denials after 3 successful appeals contact network rep and they can assist you.