Wiki After hours care

[shannon.flaherty]

One of our physicians had to come in to the office on a Sunday for a Nursemaids elbow. I billed a 99050 along w/the nursemaid elbow (24640). Insurance is denying claim stating that I need a proper modifier. Does anyone know what modifier you're supposed to use in this case?

 

[btadlock1]

One of our physicians had to come in to the office on a Sunday for a Nursemaids elbow. I billed a 99050 along w/the nursemaid elbow (24640). Insurance is denying claim stating that I need a proper modifier. Does anyone know what modifier you're supposed to use in this case?

They have an error in their bundling logic - they're trying to require a 25 modifier on 99050, but it's not appropriate to put the 25 modifier on that code. You should send a written appeal with records detailing your regular business hours, and the reason that the patient had to be seen on an urgent basis. Also advise them that 99050 is not a stand alone code - it must be billed "in addition to [a] basic service", meaning that it doesn't bundle to the basic service (or vice versa), and it would be incorrect coding to bill the services any other way. I'd send a copy of the page in the CPT book with 99050, highlighting the code description. It may still deny as a non-covered service, but at least the denial will be legitimate, and will allow you to bill the patient. Good luck!