Wiki 92928 - Quantity incorrect

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nancy.anselmo@ccrheart.com

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Ok, so an insurance co. denied payment on 92928
billed
92928
92928
93458-26-59
No modifiers on the Stents as this insurance does not want them on, so I send in the Cath report and a rationale letter for the 59 on the Cath. Now these were stents in the LC and LD. They paid one of the 92928. The denial code is: Quantity incorrect, add-on code required with primary service. This is not an add-on code. Do I need a 59 on the second one? Thanks Nancy
 
If they won't take the vessel modifiers, then yes, I would append the -59 modifier. That way they know that it's separate from the first stent.
 
If you are filing a written appeal, it might help to include a copy of the CPT book for the code 92928 showing it is for each main vessel and not an add on. They should know the definition of codes but I think we've all had the experience that their systems don't.
 
Ok, so I just received a call from the local insurance for this claim and they said that the claim was processed correctly and the McKesson denial is correct. That they paid for the first 92928 but that the second one should be 92929. Does this seem correct, it goes against how we were told to use these 2 CPT codes and the definition for the 92929 says additional branch. These were stents in 2 major coronary arteries. So I think McKession is wrong and so is this denial. I am having such a hard time with reps listening to me
 
Don't give up, I've had this experience with an insurance company that used McKesson edits. File an appeal or write a letter to the Medical director explaining why their denial is not correct per CPT definition. I would include a copy of your original claim, procedure report, copy of CPT book and Insurance co eob denial.

I had to file a request for reconsideration with the Medical Director but they DID change their edit.
 
nancy.anselmo@ccrheart.com said:
Ok, so I just received a call from the local insurance for this claim and they said that the claim was processed correctly and the McKesson denial is correct. That they paid for the first 92928 but that the second one should be 92929. Does this seem correct, it goes against how we were told to use these 2 CPT codes and the definition for the 92929 says additional branch. These were stents in 2 major coronary arteries. So I think McKession is wrong and so is this denial. I am having such a hard time with reps listening to me
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You're right, their denial is wrong. stick to your guns and don't let them push lower reimbursement down your throat.
 
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