Tara0513
Networker
My billing team has been questioning me if we can use modifier 59 for these two different scenarios, and I am really unsure of the answer. Hoping someone can help me.
Scenario 1: Gastro referring provider takes two specimens during a procedure. The ordering provider sends one of the specimens to our independent lab and sends the second specimen to a completely different lab (I am not sure why he does this), now our claim is being denied as "THIS SERVICE IS NOT PAID. THE PAYMENT FOR THIS SERVICE WAS MADE FOR THE SAME DATE OF SERVICE TO A DIFFERENT PROVIDER". Now can we append modifier 59 on our claim to show that it is different service from the other lab? I am not sure if this is correct coding/billing. Is there any way around this? We have tried to appeal explaining we are a separate lab etc. but it has not worked in our favor.
Scenario 2: Urgent care facility submits a nasal swab to our lab to test for Covid 19, Influenza a&b and RSV. Now with United Healthcare per their policy POS should be where the specimen was obtained (20-urgent care) not POS of where the specimen was processed (81-independent lab) United is now denying our claims for max units reached. The AR department stated that they have submitted corrected claim after appending modifier 59 on our claim and United is processing the claim. They said they even have done this with some Aetna claims as well. Is this the correct way to bill? I just do not know; I do not feel comfortable.
Hoping someone can clarify these two scenarios as to what is the correct way of coding and appealing, and if I am wrong in worrying that using modifier 59 is incorrect.
Scenario 1: Gastro referring provider takes two specimens during a procedure. The ordering provider sends one of the specimens to our independent lab and sends the second specimen to a completely different lab (I am not sure why he does this), now our claim is being denied as "THIS SERVICE IS NOT PAID. THE PAYMENT FOR THIS SERVICE WAS MADE FOR THE SAME DATE OF SERVICE TO A DIFFERENT PROVIDER". Now can we append modifier 59 on our claim to show that it is different service from the other lab? I am not sure if this is correct coding/billing. Is there any way around this? We have tried to appeal explaining we are a separate lab etc. but it has not worked in our favor.
Scenario 2: Urgent care facility submits a nasal swab to our lab to test for Covid 19, Influenza a&b and RSV. Now with United Healthcare per their policy POS should be where the specimen was obtained (20-urgent care) not POS of where the specimen was processed (81-independent lab) United is now denying our claims for max units reached. The AR department stated that they have submitted corrected claim after appending modifier 59 on our claim and United is processing the claim. They said they even have done this with some Aetna claims as well. Is this the correct way to bill? I just do not know; I do not feel comfortable.
Hoping someone can clarify these two scenarios as to what is the correct way of coding and appealing, and if I am wrong in worrying that using modifier 59 is incorrect.