Wiki Prolonged Evaluation & Management

[fmoore66]

Hello,
Any assistance is appreciated.

Billing CPT 99358, 99359 (prolonged Services) with 90791.
Received denial from BCBSTX. I ran through clear claim connect with Availity and received disallowed message stating: "this procedure is not recommended for separate reimbursement."

Is there a modifier that can be used to get these claims paid?

Thanks in advance.

 

[sls314]

Hello,
Any assistance is appreciated.

Billing CPT 99358, 99359 (prolonged Services) with 90791.
Received denial from BCBSTX. I ran through clear claim connect with Availity and received disallowed message stating: "this procedure is not recommended for separate reimbursement."

Is there a modifier that can be used to get these claims paid?

Thanks in advance.

The NCCI PTP edits show that 90791 conflicts with both 99358 and 99359. A modifier is not allowed to override the relationship with either code.

If you don't have an NCCI edit checker in your encoder software, you can use one of the PTP lookups on any Medicare MAC's page.

Here's a link to the Novitas lookup tool: https://www.novitas-solutions.com/s...tNWurO3zRu45VQQHOzxnt06Chya7iZpHu!-1177889899