Wiki Help with Claim

[lorig1369@gmail.com]

Can I get some input as to whether or not this qualifies as a reason for 24 modifier. Patient was seen on 6/28 for Endoscopic Plantar Fasciotomy Right foot.

On 8/3 the patient came back to the office with a chief complaint of right ankle pain due to the fact that she over did it walking at the beach. Patient was only 35 days post op at the 1st visit. Patient came in 4 times for this same problem. Blue Cross denied it, including on appeal. It is a different issue at hand but is the 24 modifier applicable in this case?

Also, on the appeal, we requested in bold letters that a “Board Certified Podiatrist” review the case. Blue Shield had a Gastroenterologist/Internal Medicine specialist do the review! Any thoughts on how to handle this. In case it is helpful, the Podiatrist is in NJ.

 

[thomas7331]

It's hard to know whether or not a modifier 24 would be supported without reviewing the provider's documentation. There are a lot of grey areas in the use of this modifier, and to make it harder, different payers use different criteria for determining what exactly is included in their global surgical package payment. For example, many payers consider treatment of complications to be part of the global payment whereas CPT states that the package only includes the usual postoperative care and that complications may be reported separately. To win an appeal, your documentation needs to show that the services in these visits is clearly unrelated to the original surgery and warrant separate reimbursement under that payer's policy. I think that requesting a specialist review is not the right way to go here since payment here is not a clinical issue, it is a reimbursement policy decision. My approach would be to look at the notes and the payer's policy side by side and to see if you can make a persuasive case for why these service meet that payer's criteria for separate payment. All that said, these types of disputes are not easy to win especially if you are dealing with a problem at the same site that was treated in the surgery. Hope this may help some.

 

[Orthocoderpgu]

Very typical insurance denial

Insurance companies usually only have one or two providers at the most to review medical information. They are usually retired providers wanting to keep busy. So asking for a Podiatrist or Foot & Ankle specialist is way beyond them.

In my mind these are two separate and unrelated issues. Plantar fasciitis causes pain at the bottom of the foot, not ankle pain. So to me this would be a separate issue and would qualify for a -24 modifier. Ankle pain is probably coming from stressed ligaments and or arthritis.

See if you can't find their "post op" policy on line which may address this. Otherwise, get your state insurance department involved. File a complaint with them. Insurance companies get fined all the time by them, but the general public is not aware of this.