Hello. We are new to billing Q4236 and are being told by the supplier that we are fine to bill this with the application of the skin graft 15275. Anthem is bundling the code though and I am curious if anyone has seen this. If so, what modifier are you using or is this correct and we should consider the skin graft part of the Q4236? Any suggestions or help would be greatly appreciated. Thanks!
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Wiki Q4236/15275 help please
- Thread starter caddellheather@yahoo.com
- Start date
We originally billed Q4236 with the JZ modifier, but the rep told us that if that denied, which it did, that we needed to remove that. Anthem denied the Q4236 stating that the JZ was an inappropriate modifier for the service. Also we are billing with DX L97.522 (non pressure chronic ulcer of other part of left foot with fat layer exposed)
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Check Anthem LCD policy also.
Most skin subs are payable by Medicare and very few by the commercial companies. These companies will tell you it's payable and then it is listed as investigational on the LCD policy.
Your office will need to have a billing aide contact at the distributor and communication in writing so you can get your account credited for the product if they advised it was payable.
Most skin subs are payable by Medicare and very few by the commercial companies. These companies will tell you it's payable and then it is listed as investigational on the LCD policy.
Your office will need to have a billing aide contact at the distributor and communication in writing so you can get your account credited for the product if they advised it was payable.
There was no waste. But Anthem didn't approve of us using the modifiers.
Thank you.
What POS are you billing?
podcoder70
Expert
First, the supplier is there to sell...so always do your due diligence before application and never go off of what they tell you. The supplier should perform an insurance verification on your behalf before the application of the product. That way if the product is used and the payer denies, the supplier will credit you the product.
The JZ and JW modifiers are for standard medicare and medicare advantage, not commercial payers. Be sure the units match the size of the product. Provide any diagnosis code that supports medical necessity, such as DM with neuropathy and/or vascular insufficiency.
If Anthem is a commercial payer and not a medicare advantage plan, most commercial payers consider skin subs "experimental" and do not cover them. Even if prior authorization is obtained and they pay in the beginning, they often recoup down the road. And finally, coding the application with the product is completely appropriate...perhaps Anthem wants an LT or RT, which is not proper coding, or perhaps they want a 59 on the application, which is also not proper coding. If you havent already called them for further direction, I would advise that...and if all else fails, appeal if able...and stop applying the product to this patient.
The JZ and JW modifiers are for standard medicare and medicare advantage, not commercial payers. Be sure the units match the size of the product. Provide any diagnosis code that supports medical necessity, such as DM with neuropathy and/or vascular insufficiency.
If Anthem is a commercial payer and not a medicare advantage plan, most commercial payers consider skin subs "experimental" and do not cover them. Even if prior authorization is obtained and they pay in the beginning, they often recoup down the road. And finally, coding the application with the product is completely appropriate...perhaps Anthem wants an LT or RT, which is not proper coding, or perhaps they want a 59 on the application, which is also not proper coding. If you havent already called them for further direction, I would advise that...and if all else fails, appeal if able...and stop applying the product to this patient.