iowagirl77
Expert
I posted this under the Modifier thread originally, but I wonder if I'd have better luck with other ortho coders:
I have a few claims that were billed with DME L1902 and L4361 on the same day where BCBS and Humana denied L1902 for bundling. They were both billed with KX and a laterality modifier. We appealed, and Humana paid but BCBS still denied, stating per NCCI it is mutually exclusive. I have searched and searched but cannot find anywhere that NCCI states this. Modifier 59 is an option for L1902, but I've never added it to DME. I would imagine it was appropriate if the two items were for different limbs, but are there other instances when would it be appropriate? i.e. daytime stability vs protection while sleeping.
I checked with my provider and he responded today:
The brace was for stability and immobilization as attempted conservative treatment. The boot is in preparation for postoperative where she will be placed in the boot after upcoming surgery. Let me know if that is not valid justification. One could also argue the brace was not enough control and so the boot was offered. The boot will be utilized after surgery and then transition back over to brace so they both will have utility postsurgical as well.
Do you think adding a 59 mod to L1902 is appropriate for this instance, or do you think it is only meant for different limbs?
Thanks!
Susan
I have a few claims that were billed with DME L1902 and L4361 on the same day where BCBS and Humana denied L1902 for bundling. They were both billed with KX and a laterality modifier. We appealed, and Humana paid but BCBS still denied, stating per NCCI it is mutually exclusive. I have searched and searched but cannot find anywhere that NCCI states this. Modifier 59 is an option for L1902, but I've never added it to DME. I would imagine it was appropriate if the two items were for different limbs, but are there other instances when would it be appropriate? i.e. daytime stability vs protection while sleeping.
I checked with my provider and he responded today:
The brace was for stability and immobilization as attempted conservative treatment. The boot is in preparation for postoperative where she will be placed in the boot after upcoming surgery. Let me know if that is not valid justification. One could also argue the brace was not enough control and so the boot was offered. The boot will be utilized after surgery and then transition back over to brace so they both will have utility postsurgical as well.
Do you think adding a 59 mod to L1902 is appropriate for this instance, or do you think it is only meant for different limbs?
Thanks!
Susan