Wiki Mod for 99291 and 36556

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tlwhlw

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Physician has given me charges for CCU time 100 minutes plus 36556. This is a Medicare patient. CCU is 99291 and 99292.

I have billed to Medicare in the past (5/2010) and this same billing was denied; Medicare considers 36556 minor surgery and will only pay the lesser of charges. They denied both 99291 and 99292, paying only 36556. I called to get more info and was told no modifier could seperate these 2 services.

This just doesn't seem right. Before I submit this claim, does anyone have any thoughts or suggestions??? I would think there is some Modifier that could seperate these and get all paid. 25, 59 ??? Help!!!

I am in Arizona, so we are with Noridian in North Dakota for Medicare.
 
tlwhlw said:
Physician has given me charges for CCU time 100 minutes plus 36556. This is a Medicare patient. CCU is 99291 and 99292.

I have billed to Medicare in the past (5/2010) and this same billing was denied; Medicare considers 36556 minor surgery and will only pay the lesser of charges. They denied both 99291 and 99292, paying only 36556. I called to get more info and was told no modifier could seperate these 2 services.

This just doesn't seem right. Before I submit this claim, does anyone have any thoughts or suggestions??? I would think there is some Modifier that could seperate these and get all paid. 25, 59 ??? Help!!!

I am in Arizona, so we are with Noridian in North Dakota for Medicare.
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Interesting. I pulled up the codes under the CCI edits in Encoder Pro and they are not bundled and there are no available modifiers under CMS for any of the codes. So you should be able to bill all three with no modifiers and be reimbursed under Medicare.

If they deny, pull up the CCI edits, print them off and send them with the appeal. There is no LCD for Noridian for these codes.
 
99291 is in the E/M section of the CPT book so you would need to protect that service from the procedure with a 25 modifier IF the documentation states the decision for the procedure was made. It is not necessary to put a 25 on 99292 as it is an add-on code as it is linked with the primary code and is not needed. Our EHR has a scrubber that will kick these out if an modifier is placed on an add-on code
 
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