Wiki Denials for bi lat procedures/state bcbs/SC

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KHH

KHH

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Aynor, SC
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I am getting alot of denials on bilateral procedures from tubes to T&A. We have been using 50 modifer. BCBS will pay for second line with 50 modifer and deny 1st line without modifer, stating that is was bundled into another procedure done on that day also:confused::confused:

any advise on G0628 being used by anyone?

also new to ENT___HELP
 
In IA BCBS pays codes with 50 modifiers at 150% billed on one line. Check to see if your state BCBS wants 50 modifers billed on 2 lines.
 
Tonsil and adenoid codes (42820 and 42821) don't take a laterality or -50 modifier (you'll see a "0" in the bilateral column for those codes on the national physician fee schedule.) Have you tried calling customer service/provider services for the tubes? The tubes do take a laterality or -50 modifier. The payer may require a 69436 -RT and 69436 -LT on 2 separate lines. Or - if it's a Medicaid plan, they may only allow one line per date of service regardless. Wisconsin Medicaid is like that. Detrimental for the providers and patients alike - for the providers to get paid for more than one procedure (or one side of one procedure,) they have to perform them on separate dates of service.
Hope this helps.
 
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