Wiki New X modifiers on Intervention

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jessica1974

jessica1974

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I recently submitted claims to Humana with a LHC, IVUS, and PCI. They were submitted as they always are with modifier 26,59 appended to the 93458. Today I received 4 denials from Humana. However they paid the LHC code and they are denying the intervention codes. When I called and spoke to a rep they stated that another modifier is needed on the intervention code. We have been told in the past, by Humana, that they did not recongize the modifiers LC, LD, or RC. My question is this: Are they now wanting these modifiers appended? Or are they wanting the new X modifiers particially the XS-separate organ or structure? Is anyone else having problems with this situation? I cannot find any documentation from Humana stating they want these modifers now appended. Any help or insight you can provide would be greatly appreciated.
 
On stenting and angioplasty I've always used the vessel codes. If by phone call you didn't find the answer maybe submitting one with the vessel code and seeing if it makes a difference will let you know if they've changed policy again. I had the same situation with BCBS and the 93571-26, in the past they had me remove the LC, LD etc. Now they are denying if those modifiers are not attached. Good Luck, billing can be fun, huh? :D
 
Do you have access to log-in to Humana's code edit simulator? If so, you can verify the coding before submission. Many payers are not following CMS' lead and accepting anatomical modifiers as more specific than 59 and its subsets.
 
I resubmitted 2 claims. One with the modifier of anatomic site and the other with one of the new X modifiers. Hoping one will give me the insight I need. I have access to the Humana sight but not to the code simulator. I did send them an email asking for guidance on this issue. Hopefully I will hear one way or the other. Thanks for the help
 
stent, cath and ivus

are you adding the modifier on the stent for the artery? I found that I have to add the modifier LC,LD or RC on the ivus as well to get paid.
 
we've found that submitting the anatomical modifier on the intervention and a -59 on the diagnostic study allows Humana to pay the claim. We've also started using XU on the diagnostic study but haven't received any feedback on that yet. XS wouldn't be appropriate on 93458 since it is not a separate organ or structure from the intervention.

example:
92928-LD w/ 414.01
93458-26-59 (XU) w/ 786.50
 
Hafidh,

I ran a quick report and it looks like we're getting paid from Medicare with the XU modifier. Here is how the claim was sent:
92928-LD w/ 414.01
93458-26-XU w/ 410.71

It doesn't look like we've had any denials so far for the cath/stent combo with an XU modifier. Also, I checked on Humana and it looks like we gave up on the XU with them (they didn't like it), we've started submitting with mod 59 and they're paying that.

We're in Arizona, so our MAC is Noridian
 
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