Wiki Urolift add on code 52442

[lgiusti]

I am hoping to resolve some controversy over the correct coding of Urolift
add on procedure code 52442. It has recommended to assign modifier 76 to
CPT 52442 for reimbursement of additional implants 5 and over. I myself have never assigned a modifier to an add on code. Interested in your opinion.

Much appreciated,
Lyn

 

[tori_ryan24]

I have never personally used modifiers for add-on codes just because there has never been a really unique situation to even attempt to use them. That is not to say it can't be done though. This particular code does have allowed modifiers (I listed them for you below) but even in the urology expert coder book it states modifiers are not applicable. my guess would be only in a very rare and special circumstance where you would even use these modifiers.

59 Distinct Procedural Service
GA Waiver of liability statement issued as required by payer policy, individual case
GZ Item or service expected to be denied as not reasonable and necessary
XE Separate encounter
XP Separate practitioner
XS Separate structure
XU Unusual non-overlapping service

Hope this helps!!!!

 

[JEYCPC]

I would not use a modifier on the 52442 code. The CPT states "each" additional code. IMHO.

 

[jackied]

While modifiers are not typically needed for add-on codes, in this situation, there is an MUE in place that only allows 3 units of 52442 to be paid on the initial claim. CMS addressed billing for additional medically necessary units when in excess of an MUE value in their FAQs: https://questions.cms.gov/faq.php?id=5005&faqId=11352

In the case of an MUE, appending one of the designated modifiers on the units in excess of 3 should allow for the initial 3 units of 52442 to get paid. The additional units will still have to be appealed to support medical necessity, but it at least allows the claim to be processed and the initial 3 units to be paid.

An example of a 5 unit procedure would be:
52441 x 1 unit
52442 x 3 units
52442- (add appropriate modifier) x 1 unit

Hope that helps,

Jackie