Wiki -79 modifier inconsistent with CPT code 20526 ????

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Jenuine

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Scenario: Patient in post-op for RIGHT carpal tunnel release is seen and given an injection into the LEFT carpal tunnel. I billed 20526, 79, LT and Medicare
denied payment stating "The procedure code is inconsistent with the modifier used or a required modifier is missing".

I called Medicare and the rep tells me "according to Medicare guidelines, modifier -79 is an invalid modifier for the procedure code I billed"..........WHAT ???
I explain the patient is in a post-op period, the patient received an injection into the carpal tunnel of the arm that did not have surgery which would make the injection unrelated to the post-op, I read the definition of modifier 79 "Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period"............then she says "according to Medicare guidelines, modifier -79 is an invalid modifier for the procedure code I billed". That's all she keeps telling me and I just can't with her any longer. This has happened once or twice before too and we never got paid.

Am I missing something??? Am I the only one this has happened to??? Please HELP!
Thank you
Jen
 
Jenuine said:
Scenario: Patient in post-op for RIGHT carpal tunnel release is seen and given an injection into the LEFT carpal tunnel. I billed 20526, 79, LT and Medicare
denied payment stating "The procedure code is inconsistent with the modifier used or a required modifier is missing".

I called Medicare and the rep tells me "according to Medicare guidelines, modifier -79 is an invalid modifier for the procedure code I billed"..........WHAT ???
I explain the patient is in a post-op period, the patient received an injection into the carpal tunnel of the arm that did not have surgery which would make the injection unrelated to the post-op, I read the definition of modifier 79 "Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period"............then she says "according to Medicare guidelines, modifier -79 is an invalid modifier for the procedure code I billed". That's all she keeps telling me and I just can't with her any longer. This has happened once or twice before too and we never got paid.

Am I missing something??? Am I the only one this has happened to??? Please HELP!
Thank you
Jen
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you could ask her to share with you where you can find that information? If it is according to Medicare Guidelines, then it must be writing somewhere. Short of that, you could certainly file a reconsideration.
 
This makes absolutely no sense to me. Contralateral versions of the same procedure and same diagnosis are clearly unrelated, so IMHO there's no reason why the second 20526 with 79 shouldn't have been paid.
 
Lashel said:
you could ask her to share with you where you can find that information? If it is according to Medicare Guidelines, then it must be writing somewhere. Short of that, you could certainly file a reconsideration.
Click to expand...
Since this is Medicare, they MAY be looking for the -XS modifier. That being said I think everyone has seen where their MAC has denied payment even though it's following CMS coding rules which they are supposed to follow.
 
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