Wiki UHC stating 43248 and 43239 are bundled

[blathrop19@gmail.com]

Hey all,

UHC is stating that those codes need a 59 modifier and will not pay without one. Is there somewhere I can report this to try and get them to change it other than their own claims department? Has anyone else run into something like this and do you know what my next step is other than just changing the coding with an incorrect modifier?

Thanks,

Bob

 

[DEDGE CGIC]

The usage of the 59 modifier-Distinct procedural service, is the appropriate modifier to use when billing multiple codes withint the same family of CPT codes to differentiate the codes from one another. This should be required by all payers for correct reimbursement. Hope this helps.

 

[mitchellde]

both of these codes are for a dilation and there fore cannot be billed for the same session. If however they are 2 different sessions on the same day then you can use a modifier to show this. You should never just use a 59 for a bundled procedure, they are bundled for a reason and you can unbundle only when documentation supports it. Without the note I cannot tell whether it is appropriate to append a modifier.

 

[blathrop19@gmail.com]

Hey Mitchellde I think you might have misread or I'm missing something, but it was 43239 (egd with biopsy) and 43248 (Egd guidewire dilation).

Bob

 

[mitchellde]

SORRY I DID MISREAD MY BAD! SO now that I am on the right page I agree there should be no need for a 59, just for grins have you checked the CCI edits for both component of comprehensive and mutually exclusive status? The only thing that makes sense is that they are calling them mutually exclusive. Barring that I see no need for a modifier.

 

[cingram]

You do need a 59. go to medicares website and look up "endoscopy families"

 

[blathrop19@gmail.com]

Hey cingram,

I went to Medicare's website and put "endoscopy families" in the search bar and didn't find anything. I may have been taking your request a tad literal or I was searching in the wrong place. I'm going off of Medicare's NCCI edits from:

http://www.cms.gov/NationalCorrectCodInitEd/01_overview.asp#TopOfPage

According to their edits its not needed, but if you see something I'm not please let me know.

Thanks,

Bob

 

[cingram]

https://www.noridianmedicare.com/sh...oscopy_Families_and_Payment_Rules_Updated.htm

the codes on the left are teh base codes and the codes on the right are all bundled in to that base code. Related endoscopies need a 59 unrelated need a 51. Everytime I have had a claim denied for them bundeling this I call up the insurance and refer them to this document and it gets paid everytime.