Wiki AS Modifier Denials!!!

[btadlock1]

I'm having an issue with a local Medicare carrier, and I'm looking for some documentation, one way or the other.

We have some claims that keep denying for an FNP, who's performing burn debridements on her own. We're billing 16030, with no modifiers, under the FNP's own provider numbers. We keep getting denied by one particular insurer (on Medicare Advantage plan), saying that a modifier is required because the performing provider is not an MD.

They want an AS modifier. I have explained that my understanding of the AS modifier, is that it's for use:
1. When the provider is assisting at surgery, and not performing services independently, and
2. When the services are being billed under the supervising physician on behalf of the NPP.

The response I got from their auditor, was that we need to add the AS modifier so that they can tell that the provider is not an MD (despite the fact that we're billing with FNP provider type 50, and she's credentialed as an FNP), and that if she performed the services independently, and not as an assistant at surgery, we'd have to submit records to prove it.

Has anyone else ever run into this? I didn't think that it would be assumed that the provider was an assistant at surgery, just because they weren't an MD (and that I'd have to prove otherwise), and I've never had any other payor tell me that we need to append an AS modifier, simply to show that the provider's not an MD, when we're not billing under an MD's credentials. I've asked them to show me where they're getting their info, but they've kind of been dodging my questions. The only info I can find that supports my explanation of using the AS modifier on claims billed under the supervising MD, is actually on BCBS's website, which does me no good, here. Does anyone know of a CMS/MAC policy that spells this out in black and white?

Any help is much appreciated, even if it turns out I'm wrong on this.

 

[SCOLTON]

It sounds to me that you are right......

But I wanted to clairify that the FNP is performing the debridement completely by herself not as part of another procedure that is performed by the physician at the same setting or on the same DOS. In this case you would append modifier -AS as the service is rendered as a part of another procedure. But I'm sure you know this already.

You appealed on the correct basis scope of practice for the FNP.... Did you send in her state licenseur, state law pertaining to NPP services in you state and the signed contract between her and the physician?
Sounds like you'll have to deal with the plan administrator/provider relations.....

I dealt with something similar and despite our efforts payment remainded denied due to the insurance policy!!

Sabine Colton, CPC , CCC

 

[MMAYCOCK]

AS Modifier

We had a similar issue with a payer. It wasn't a matter of incorrect coding or billing. The issue was the way they needed the claim submitted in order to get it through their payment system. We finally got someone in their implementation department to explain it to us. They paid non MDs at a different rate and without the modifier attached, their system had no way to direct the claim for proper payment.

We requested and received billing instructions in writing from our payer rep and have been billing them as requested by the payer and noting on the claim that it is billed based on a payer system restriction in case someone who is not familiar with our inquiries question why we are not using the modifier correctly.

The argument could be made that they need to get it together and it would be true, but there are only so many flags to plant!

 

[btadlock1]

We had a similar issue with a payer. It wasn't a matter of incorrect coding or billing. The issue was the way they needed the claim submitted in order to get it through their payment system. We finally got someone in their implementation department to explain it to us. They paid non MDs at a different rate and without the modifier attached, their system had no way to direct the claim for proper payment.

We requested and received billing instructions in writing from our payer rep and have been billing them as requested by the payer and noting on the claim that it is billed based on a payer system restriction in case someone who is not familiar with our inquiries question why we are not using the modifier correctly.

The argument could be made that they need to get it together and it would be true, but there are only so many flags to plant!

I think that is what their argument is - mine is that, if we need to make special accomodations to get through their edit system (particularly for a Medicare Advantage plan, and not a commercial policy), then they should specify it with a written policy in their provider manuals, and not try to hide behind some non-existent CPT or Medicare guideline...so frustrating!

 

[MMAYCOCK]

AS Modifier

I think that is what their argument is - mine is that, if we need to make special accomodations to get through their edit system (particularly for a Medicare Advantage plan, and not a commercial policy), then they should specify it with a written policy in their provider manuals, and not try to hide behind some non-existent CPT or Medicare guideline...so frustrating!

You are preaching to the choir!