Wiki 59 Modifier Help

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ckerley

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Crossville, TN
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Good afternoon.
I'm having trouble with TriWest on a VA patient that we performed an in office excision, cyrosurgery, and liquid nitrogen on.
I billed it as 11602 - 59
12031 -59
17261
17110 - 59
17000 - 59
which from what I can tell is correct, but Triwest denied the 12031, 17261, & 17000 "the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated."
I'm just curious for any help/opinions/advice/guidance on the use of the modifiers here.

Sincerely,

Christy
 
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Your modifiers look correct to me, but since the payer message states that these are being denied against a procedure 'that has already been adjudicated', this suggests to me that there is another claim that has previously been processed and paid for this patient that is causing this denial. It could be that these fall into the global period of a previous surgery by your provider, or else another claim (perhaps a duplicate) with services for this date has already processed and paid. I would check your patient's claim history, or contact the payer if you do not find anything that would have caused this.
 
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Thank you!
I double checked the claim history and nothing would fall into the global period. So I guess I'll have to the modifier battle with TriWest via appeal, because I've discussed this with them already.
Thank you so much for your reply
 
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TriWest seems to be very particular about coding/billing...we always have to be sure they have pre-authorized all visits for a calendar year (upon request, they send us a document with date parameters).

What comes to mind for me:
-Are the different skin lesion removals clearly coded as being in different anatomical locations (use RT, LT if possible, which it frequently is not) Their system may be thinking some or all codes are for the same lesion otherwise and so would reject the others.
-If any of the procedures are on the same lesion (12031 repair for 11602?), then 59 is not appropriate to use (no mod needed).
-I found this Mod 59 article yesterday that I found helpful (especially example #4, even though it uses feet for the scenario) https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf

Best of luck with this! (I hope you post something about what worked in the end.)
 
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