Wiki G0260 Medicare denial to medical necessity

[daboronda]

We recently received a denial to medical necessity for this code in our ASC. It was billed with the SG and LT modifiers along with fluoro-77002-59 as instructed in the LCD, which denied to bundled. Has anyone experienced this? Checking to see if anyone has a reason for medical necessity before I call. Thank you!

 

[thomas7331]

Medical necessity denials are usually due to a failure to have a diagnosis code on the claim that the LCD requires - without knowing what your provider documented and billed for a diagnosis, it's not really possible to help you with that one. As for the bundling denial, that appears to be correct since G0260 includes guidance. I'm not sure how you could justify the use of a modifier 59 in this situation and my guess is that 77002 is not appropriate here.

 

[574coding]

Is anyone getting code paid by Medicare G0260? We have tried everything and have called Medicare and we are not getting anywhere. We do not know who we need to reach out to get it fix. I think this is a Medicare edit issue.
THank you

 

[csardone]

I am also having trouble getting G0260 at our ASC. I also added 77002 because in the LCD it states "ASC facility claims only: G0260 MUST be billed with fluoroscopy (77002) or CT (77012). Then we got denial for bundled service.. not sure what else to do

 

[nsteinhauser]

Also gettting denials. Adding a 77002 - 59 was mentioneed in one of the LCD's I read from another contractor, adding a plain 77002 was mentioned in the LCD from my contractor (NGS). So, at least according to the LCD's, adding a 77002 is correct. But why the sudden denials of G0260 for ASC's? Has anyone been able to show their Medicare contractor the LCDs that are saying this? To add the 77002? Maybe their claims adjudication software doesn't allow the 77002?
And a fyi for Daboronda, Medicare discontinued use of -SG modifier in 2008. We still have some payers that want it for ASC charges (WI MCD, workers comp ins., etc.) but not our Medicare contractor.

 

[amaabrego83@yahoo.com]

i have also experience the same issue. Under CMS billing and coding guidelines ASC must bill G0260 with 77002 mod 59, but our claims are still denied for medical necessity.

 

[amaabrego83@yahoo.com]

I spoke with Noridian Medicare: I was told we should bill G0260 RT or LT, 77002-59, TC.. appeal claim LCD denial, representative believes it may be a system issue on their end.

 

[nsteinhauser]

I spoke with Noridian Medicare: I was told we should bill G0260 RT or LT, 77002-59, TC.. appeal claim LCD denial, representative believes it may be a system issue on their end.

Oh interesting. Thanks for the tip.

 

[glendawilson]

I have tried everything to get ours paid. My appeals are getting denied also and all documents show medical necessity and has appropriate dx to cpt in relation to the LCD. We prove Flouro as the edit will not allow the 77002 to go through. Billilng all with appropriate modifies as designated in the LCD. All deny. Has anyone gotten theirs to go through? I am currently waiting for the results of my second level appeals.

 

[johanam1989]

Just make sure your diagnosis is in the LCD, and you have a lateral modifier. It will be denied, but just open a reconsideration, supply your documentation, chart docs, and explain how per the LCD the procedure is medically necessary (make sure your icd10 code is in the LCD) and it should get paid. I have done this three times since this started happening in the beginnng of 2023. Unfortunetly it does not seem like an issue they are working or fixing anytime soon

 

[cubuscrystal]

I use G0260 and 77002-59-26 and ours are getting paid however UCare Advantage is denying our claims and I think they may want the 77002 as well.