Wiki Commercial Carrier denial of 96521

[gvp1792@aol.com]

I work for a large Hematology/Oncology group and we are seeing denials from the major commercial carriers for CPT 96521. It is being billed with 96411,96413,96417, 96366,96367,96375 depending on the patient. The -59 modifier is added. UHC is denying the 96521-59 as included in the allowance for another service. However, it will deny without the modifier. Any ideas? Thanks!

 

[alannae]

We have been having the same problem. I'm guessing it's the same company.

The modifier is appropriate assuming the documentation supports the refill/maintenance of the pump as distinct from the other procedures. Without the modifier, the code 96521 should deny. (see the NCCI edits http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html)

Based on this, what you (and I) are billing should pay, but we are at the mercy of these companies to follow the rules.

I have had limited success appealing these denials. I have been submitting supporting documentation that includes:
- a cleaned copy of a Medicare EOB showing payment for an identical claim
- a printout of section 30.5 of Chapter 12 of the Medicare Claims Processing Manual
- an article from Medicare Quarterly Provider compliance Newsletter from Feb 2011 called "Recovery Audit Finding: Chemotherapy Administration and Non-chemotherapy Injections and Infusions - Incorrect Coding"

I also have included a letter outlining the description and use of the codes in question. My success rate on getting the codes paid is probably around 70%. I think it depends on who is reviewing the appeal at the insurance company.

good luck!