Wiki 64718 Ambetter bundling

[bkerste]

Hello. I'm new to ortho coding and am not very familiar with what bundles. I have a surgery that is billing 25115, 64718-59, and 24075. Ambetter is denying the 64718 for bundling. I have checked our code edit program and it shows there should be not bundling issues with a 59 attached to 64718. Has anyone else run into this issue? How should I approach an appeal?

 

[Orthocoderpgu]

In order to use a modifier -59, you need to ask yourself "Does it qualify for a modifier"" first. If 64718 was performed through the same incision as 25115, it would not qualify. My guess is that these were performed through separate incisions so the next step if that is true is to ask "Is there a separate diagnosis for 64718"? Has your surgeon documented G56.21 or G56.22? If your surgeon has, you may need to appeal. In my appeals I always start off by stating why the code was denied and why. And then I explain why the codes "qualify" to be billed together and not bundled. I include a copy of the op note showing the surgical approaches and procedures.

 

[bkerste]

In order to use a modifier -59, you need to ask yourself "Does it qualify for a modifier"" first. If 64718 was performed through the same incision as 25115, it would not qualify. My guess is that these were performed through separate incisions so the next step if that is true is to ask "Is there a separate diagnosis for 64718"? Has your surgeon documented G56.21 or G56.22? If your surgeon has, you may need to appeal. In my appeals I always start off by stating why the code was denied and why. And then I explain why the codes "qualify" to be billed together and not bundled. I include a copy of the op note showing the surgical approaches and procedures.

Thank you so much for the information. It was done through a separate incision sight and we did use 2 separate dx. I will try doing the appeal and highlight the separate incision sights and different problems. I really appreciate you giving me some guidance on how to approach the appeal, it's very helpful.