Wiki Ophthalmology coding getting denied by Medicare. Help!

[DEBI MCLAUGHLIN]

Hi. Claims for exam (92014, 92004 with modifier 57) and in-office laser 66821 getting denied. I was told to add modifier 57 to the exam when a decision for surgery was within 24 hours, but was not told that the 66821 also needed a modifier. Medicare split the claim and paid for the exam, but are denying the laser for a wrong modifier. I resubmitted with modifier 59 but that was also denied. Is there another modifier or did I use the wrong modifier on the exam? Thank you!

 

[BooValu23]

Try modifier -52 on code 66821.

https://files.medi-cal.ca.gov/pubsdoco/outreach_education/.../ab-io_2016.pdf

NOTE: If that modifier works, I wouldn't know why the surgery is considered a "reduced service" with the eye exam. I'd question your MAC on that one. Good luck!

 

[DEBI MCLAUGHLIN]

Try modifier -52 on code 66821.

https://files.medi-cal.ca.gov/pubsdoco/outreach_education/.../ab-io_2016.pdf

NOTE: If that modifier works, I wouldn't know why the surgery is considered a "reduced service" with the eye exam. I'd question your MAC on that one. Good luck!

Kinda new to this, what's MAC?

 

[mitchellde]

Since the 66821 is a procedure that by description is subsequent to the extrascapular cataract surgery, and if the patient is still in the 90 global for that procedure they are looking for a 78 or 58 modifier. also you would not then be able to bill the 99214 or the 92004.

 

[DEBI MCLAUGHLIN]

Since the 66821 is a procedure that by description is subsequent to the extrascapular cataract surgery, and if the patient is still in the 90 global for that procedure they are looking for a 78 or 58 modifier. also you would not then be able to bill the 99214 or the 92004.

It was not during the post op period, so I really don't know what they want. Procedure was performed in office, did I use the wrong code on the exam? They won't tell me what code they're looking for on the procedure. Thanks.

 

[JGMullen]

I would think a 57 on the exam would be all you need. So unless you are in the global period for the original cataract surgery the 66821 doesn't need a modifier, if you are within the global period then you would add the 78 on the 66821. Is this a medicare advantage plan? We are running into a lot of those plans that still want the eye modifier on the CPT code even though the eye is shown in the diagnosis.

 

[DEBI MCLAUGHLIN]

I would think a 57 on the exam would be all you need. So unless you are in the global period for the original cataract surgery the 66821 doesn't need a modifier, if you are within the global period then you would add the 78 on the 66821. Is this a medicare advantage plan? We are running into a lot of those plans that still want the eye modifier on the CPT code even though the eye is shown in the diagnosis.

It's not, it's just Medicare but I'll try that. That's what I thought when I billed it, that no modifier was needed on the 66821 if the 57 was on the exam. If it still rejects I will probably have to appeal and see what happens. If you can think of anything else please let me know. Thanks so much!