Wiki Denial

[solocoder]

A patient is in a 90 day global for a surgery done 3/30/15 and has a toenail removed on 4/13/15, submitted with a 79 modifier and a toe modifier. Coventry has denied for "inappropriate modifier". I called Coventry and was told the patient is not in a global. When I pointed out the 3/30 surgery, I was told to submit records.
I'm wondering if I shouldn't just take off the 79 and resubmit? Or will it somehow come back to bite me later if I don't submit records?

Any thoughts?

 

[dclark7]

A couple of questions come to mind, first, had Coventry processed the surgery done on 3/30 at the time of the denial, if not they wouldn't have had a record of the surgery which may be why they denied your claim for the modifier. Second, did the same doctor that removed the toenail do the 3/30 surgery, if not then you don't need a modifier at all.

If you had to point out the 3/30 surgery this seems to indicate that they didn't have the charges on file at the time.

 

[solocoder]

Thanks for your reply, dclark7.
Researched this some more. In an interesting twist, the patient was delinquent in their insurance premiums at the time the initial surgery was submitted, which caused it to deny. Therefore... no global. Patient later caught up on their premiums, coverage was reinstated (obamacare grace period), and claim was paid retroactive. So now, there IS a global from the first surgery.
Think I better just submit the records.