Wiki CPT 36561 & Modifier 79 - Humana MCR denial

[SSThomas03]

Humana Medicare denied CPT code 36561-79,LT with ICD-10 codes Z45.2 and C50.911.

Patient had a left port-a-cath inserted within a 90-day global period of a right partial mastectomy. CPT code 36561-LT was submitted with modifier 79 to let the payer know the port was in a different anatomic location and was not staged or more extensive than the partial mastectomy. Unfortunately, the payer denied the code stating the "diagnosis was inconsistent with the procedure" and "incomplete/invalid procedure modifier(s)" were submitted. After additional review with the payer a representative stated the code was denied due to the "diagnosis code does not correlate with the modifier". We have not had any issues with coding or reimbursement with this type of situation in the past. We submitted an appeal, but the payer stilled denied the charge.

Has anyone had this problem, and, if so, how were you able to resolve it?

 

[mk2001]

Humana Medicare denied CPT code 36561-79,LT with ICD-10 codes Z45.2 and C50.911.

Patient had a left port-a-cath inserted within a 90-day global period of a right partial mastectomy. CPT code 36561-LT was submitted with modifier 79 to let the payer know the port was in a different anatomic location and was not staged or more extensive than the partial mastectomy. Unfortunately, the payer denied the code stating the "diagnosis was inconsistent with the procedure" and "incomplete/invalid procedure modifier(s)" were submitted. After additional review with the payer a representative stated the code was denied due to the "diagnosis code does not correlate with the modifier". We have not had any issues with coding or reimbursement with this type of situation in the past. We submitted an appeal, but the payer stilled denied the charge.

Has anyone had this problem, and, if so, how were you able to resolve it?

If we performed a lobectomy and place an infuse-a-port within the global period, I bill 36561,58,LT with the lung cancer dx as the primary and only code because we are still treating for the original condition. I only use the Z45.2 dx if we replace or remove the catheter.

Hope this helps.

 

[dkissel]

Humana Medicare denied CPT code 36561-79,LT with ICD-10 codes Z45.2 and C50.911.

Patient had a left port-a-cath inserted within a 90-day global period of a right partial mastectomy. CPT code 36561-LT was submitted with modifier 79 to let the payer know the port was in a different anatomic location and was not staged or more extensive than the partial mastectomy. Unfortunately, the payer denied the code stating the "diagnosis was inconsistent with the procedure" and "incomplete/invalid procedure modifier(s)" were submitted. After additional review with the payer a representative stated the code was denied due to the "diagnosis code does not correlate with the modifier". We have not had any issues with coding or reimbursement with this type of situation in the past. We submitted an appeal, but the payer stilled denied the charge.

Has anyone had this problem, and, if so, how were you able to resolve it?

We have had this same issue with Priority Health but upon reconsideration it was paid. If it continues, you could let them know you will be going to the next level and filing with CMS. This may make them manually review your claim.