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We are having trouble being paid by BCBSIL for billing codes 28140(w/RT OR LT modifiers) and code 28288. The denial reason is that the proper modifier is not being used. Anybody having any luck getting paid
These codes were billed separately two different patients but same insurance. We have tried everything from billing these codes with the RT and LT modifiers , to the T modifiers and just leaving it without anything and nothing has worked. When we have called the provider line all they can say is that it's being denied because the proper anatomical modifier is not being used. We have even try to do a claim reconsideration with the OP report and are still being denied. Medicare , Aetna and United Health Care have all paid on these CPT codes with just the RT and LT modifiers so I'm not sure what else we can do.It depends. Is it only one case or multiple cases? What else was done during each? Should both codes be reported together according to the operative report, other CPT on the claim, and edits? Does this payer use McKesson edits instead of NCCI? Were both codes done on the same MT? Does this payer want 51 modifiers when there are multiple CPT reported? Does the payer want the toe modifiers instead of RT/LT (even though these are not phalanges?). That code combination is questionable to me.
It is difficult without an op note. Was the coding correct in the first place?
The denial states the wrong anatomical modifier is being used or is missing.Yeah, the provider line isn't always going to have correct or helpful info. What is the actual denial reason code on the claim?
Were the diagnoses coded correctly? This denial can be when someone makes a mistake with the last digit of the diagnosis is incorrect. Like, someone accidentally coded a laterality conflict. They coded RT diagnosis when it was on the LT side and you have a LT modifier but the dx says RT, for example. You could change around the modifiers all you want, but if the diagnosis does not match it would still be denied. Or, the payer is stating it's a modifier issue when really it is denying for some other reason.
Other than that, I would have to see the op note and what was billed (redacted).
That claim was only billed for one line 28140 with RT modifier and 78 after it followed a previous Toe Amputation, with a diagnosis of M86.171You did a corrected claim with the correct T modifier too and that had the same denial?
Something is not adding up.
What are all of the CPT and dx codes on the claim? Is it bilateral surgery or only single side? If there are multiple claim lines with other dx or other sides from RT, is a diagnosis pointer accidentally pointing to the wrong dx? If a hammertoe was done at the same time, does it accidentally have the hammertoe dx on it?
Grasping at straws lol
The corrected claim was than billed with 28140 with a toe modifier, and than again with just the 78 modifier , which all have been denied.That claim was only billed for one line 28140 with RT modifier and 78 after it followed a previous Toe Amputation, with a diagnosis of M86.171