Wiki Cci edits for 43248, 43239

[kathleenw84]

I was posting a payment on the 43248 from Blue Cross and they paid us the 59 modifier amount even though we attached the 59 to the 43239. We is this allowable? Also, when I check in the CCI edits, neither code shows the other as billable with the other even with a modifier. This has to be the wrong! What is correct?

 

[eescalante]

We recently had the same problem with BCBS with combinations of colonoscopy codes and hemorrhoid banding - they were paying the colonoscopy as the 2nd procedure at 50% rather than paying the hemorrhoid banding second. We had to call and speak with provider services and formalize our complaint against that processing. The two codes you show above are billable together with the modifier. There is no CCI edit because there are no restrictions on billing the two together.

 

[FTessaBartels]

Highest RVU

I was posting a payment on the 43248 from Blue Cross and they paid us the 59 modifier amount even though we attached the 59 to the 43239. We is this allowable? Also, when I check in the CCI edits, neither code shows the other as billable with the other even with a modifier. This has to be the wrong! What is correct?

43239 has the Higher RVU value, so it would appropriate to attach any required modifier to 43248.

I am assuming they paid you in full for 43239?

Hope that helps.

F Tessa Bartels, CPC, CEMC