Wiki Mutually Exclusive Appeal with Medicare

[wfriddle]

Has anyone had any luck appealing these type of claims with Medicare? I have a procedure in column two of the NCCI edits that will not allow a modifier override but my provider insist that it should pay, claiming that 1) It's the standard of care to perform both procedures (which of course doesn't necessarily mean they will pay separatley) and 2) Two seperate machines are used, so even though you do have to pass through the site of one procedure to perform the other procedure they are done with seperate machines therefore should not be integral to each other.

I have already submitted a redetermination, which denied, and I was wondering if anyone else has any luck with such appeals or if it is worth further pursuit.

Any advice or examples of successful appeals would be greatly appreciated.

 

[mitchellde]

If it is mutually exclusive and no modifier allowed then you should have never billed both procedures in the beginning. If you were paid for the more pricey procedure then consider yourself lucky as the norm is to pay the least expensive. There is no way to over ride this edit. By submitting the claim with both codes and then trying to appeal the denial will only get your practiced flag for audit and review.