Wiki can an insurance company assign a modifier to a claim?

[Cavalier40]

We are having issues with Aetna applying a 26 modifier to urine drug screens, then in the same remittance denying the claim stating that they do not pay for just the professional component.

I work with a free standing inpatient drug treatment facility and bill with POS 61. We bill 80305 with a QW modifier.

Aetna says that their payment policy does not pay for the code outside of the office. While if that is written in the plan documents, I can understand a denial for invalid POS, I do not understand them applying the modifier themselves.

Any insight would be helpful

 

[thomas7331]

Insurance companies are not allowed to 'change' the coding of claims from how they were submitted by the provider. However, they will sometimes manipulate a claim as part of an internal process to get it to pay correctly - my understanding is that this is not supposed to be visible outside of their system. It sounds like this is what they are doing in your case. 26 is not a valid modifier for this code, but my guess is that they are identifying based on the inpatient place of service that the technical component of this service would not be payable to an outside provider since it would be included as part of the facility fee. They are probably adding 26 to force the claim to only pay the professional component, and since there is none for this code, it denies.

Clinical lab services provided to inpatients are normally billed by the facility as a line item on the UB claim - is there a reason you're billing this as an separate claim?

 

[Cavalier40]

we did an across the board change since there was confusion with the authorized room and board days when billing the labs and R&B charges together. Some payers would only pay the labs and not the R&B charges so we decided to separate the claims. This seems to work with all payers other than Aetna.

 

[crichmond]

We are also getting a denial from Aetna stating that 300 revenue code with 80305 is not an inpatient revenue code, the denial states, "Inpatient bill requires minimum of one inpatient revenue code."
Every other payer processes the claims except for Aetna if the bill type is inpatient. Has anyone else ran into this? If so, do you have a resolution?

 

[CodingKing]

We are also getting a denial from Aetna stating that 300 revenue code with 80305 is not an inpatient revenue code, the denial states, "Inpatient bill requires minimum of one inpatient revenue code."
Every other payer processes the claims except for Aetna if the bill type is inpatient. Has anyone else ran into this? If so, do you have a resolution?

Lab work should be on the same claim as the other facility charges. Is it being sent as late charges and they are just not accepting ancillary services under the late charge only Bill type 115?

 

[crichmond]

Lab work should be on the same claim as the other facility charges. Is it being sent as late charges and they are just not accepting ancillary services under the late charge only Bill type 115?

We took over billing from another company and they were submitting all labs separate from other treatment, I will try submitting the past ones as a late charge to see if that works, and submit the charge with the R&B charges going forward to see if that works.

Thank you for your input!!

 

[CodingKing]

We took over billing from another company and they were submitting all labs separate from other treatment, I will try submitting the past ones as a late charge to see if that works, and submit the charge with the R&B charges going forward to see if that works.

Thank you for your input!!

I'm not sure why they would have they were doing that other than hoping they get paid in addition to any Per Diem, or DRG payments. Luckily as you are seeing here the system is configured to stop this.

 

[1formissy]

Insurance companies are not allowed to 'change' the coding of claims from how they were submitted by the provider. However, they will sometimes manipulate a claim as part of an internal process to get it to pay correctly - my understanding is that this is not supposed to be visible outside of their system. It sounds like this is what they are doing in your case. 26 is not a valid modifier for this code, but my guess is that they are identifying based on the inpatient place of service that the technical component of this service would not be payable to an outside provider since it would be included as part of the facility fee. They are probably adding 26 to force the claim to only pay the professional component, and since there is none for this code, it denies.

Clinical lab services provided to inpatients are normally billed by the facility as a line item on the UB claim - is there a reason you're billing this as an separate claim?

Medicare changes the coding of claims for reimbursement. I see modifier 51 appended to CPT codes that were not originally billed with that modifier.

 

[CodingKing]

Medicare changes the coding of claims for reimbursement. I see modifier 51 appended to CPT codes that were not originally billed with that modifier.

CMS for example states:

Medicare doesn’t recommend reporting Modifier 51 on your claim; our processing system will append the modifier to the correct procedure code as appropriate.

Other payers that base off CMS typically the same.