Wiki WHAT MODIFIER TO USE WHEN BILLING 90471 AND 99406?

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prusso

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Ringgold, GA
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I have been having an issue getting paid by UHC Americhoice and dual complete for both my smoking cessations and vaccines. If I send my smoking cessation without a modifier it will deny as service bundled. If I add a 59 modifier it denies as procedure inconsistent with the modifier used/required modifier missing. I am at a loss and when I call they have no idea what I am talking about and when I appeal they just tell me to send a corrected claim (which has already been done) or decision upheld with no explanation. Any suggestions as to what modifier I should be using? or anyone else have this same issue? This is just a regular medical clinic that does office visits.
 
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Yes, I am aware of the CCI edits for these codes and I have tried the 59 and they are telling me that it is incorrect. I have sent in an reconsideration and they are still telling me it is incorrect. I looked into the X modifiers however none of the descriptions seem to apply, unless I am misreading them. Have you heard of the GP, GO and GN modifiers? From reading the policy for Amerigroup - Policy to procedure - it almost sound like they want one of these modifiers, but their definitions are not for a regular mds doing E/M visits. These are for physical therapy, occupational therapy or speech-language pathology plan of care. I may again be misreading.
 
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If you check the CCI edits, you'll see that 99406 is a Column 2 code when billed with 90471. You need either a -59 modifer OR one of the X{EPSU} modifiers on 99406 if it is supported by the documentation as a separate service.
 
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I'm not able to locate the Amerigroup policy; can you provide a link? Unless they have redefined the GP, GO and GN modifiers for their own purposes, I would not be comfortable using those. Probably the only X modifier to use would be the XU and that's basically like reporting the 59 modifier. Amerigroup has been unable to tell you specifically which policy they are applying to your claim? Can you escalate to your provider rep, if you have one?

When I run the CCI edits for your code combo in Codify, I get the following result, not sure if it will be of any help:
CCI Validation Results:
Code 99406 is a column 2 code for 90471, but you may use a CCI-associated modifier to override the edit under appropriate circumstances.
CCI Edit Rule:
CPT Manual or CMS manual coding instructions
The current CCI-associated modifiers are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, LM, RC, RI, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, XE, XP, XS, XU, 24, 25, 27, 57, 58, 59, 78, 79, and 91. (View CPT® and HCPCS modifiers.)
 
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One more question - everything I can find from Amerigroup in relation to smoking cessation indicates they only allow 99407. Does the policy you have support that?
 
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