Wiki Screening colonoscopy

[beachgrl62]

We have gotten denials on all the screening colonoscopies that we have submitted with the new modifiers. We attended an anesthesia conference and were told that these modifiers override the need for medical necessity. Can anyone verify this? My managers want something in writing that states this. Any help is appreciated. Thanks!

 

[LeslieJ]

Screening Colonoscopy

Just a quick question to ask: did you use the screening Dx V76.51 in conjunction with the 00810-33 or -PT?

The next thing you need to realize is just because CMS says so doesn't always mean that the private payers automatically follow suit. Many do, this is true, but some don't. We see this all the time with modifier 50 vs RT/LT for some payers & we see it all the time with various qualifying circumstances. Some are paid, some aren't. It's all relative to what the payer guidelines are.

The only entity that can answer your question with any definitive answers is the payer you're trying to bill. It may be that it's not in your contract (yet) or not in their adjudication system (yet).

Contact your payer for their rules. You might even have to talk with the payer rep to find out the reason for the denials.

L J

 

[akj]

According to AAPC Healthcare Business Monthly CEU testing rationale, modifiers 33 and PT are used on Medicare claims only, unless a payer issues specific instructions regarding how to report them.

 

[skintzley]

According to CMS Guidelines the 00810 is no longer on the LCD list for requiring medical necessity. this was effective 04/09/15