1. Karen H
   Posted 5 months ago #
   

   medicare billed cpt 62311 x one unit with modifier 79 and J1040 x two units. reason codes for denial CO-50, M25, N115.

   Pt was previously seen almost two months prior for cpt 99213 mod 25 and cpt 17000 which paid.

2. SuperCoder
   Posted 5 months ago #
   

   What are the DX code for your claim and what your locality (state) is?
   *****
   As per your denial code you should look for the following
   1.) Check out for the medical necessity and DX codes.
   Ref : https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=29165&ContrId=197&ver=8&ContrVer=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&CptHcpcsCode=62311&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&

   *****
   2.) Check the LCD for your state.
   ****
   Accordingly change (correct) the DX on the claim and re-appeal.

3. Karen H
   Posted 5 months ago #
   

   DX was 724.5 back pain. Out locality is Oregon. What is LCD mean?? Sorry I am fairly new to all this. We have billed Medicare in the past using all the same CPT/J-code/DX code and it never had a problem before. Is my modifier wrong also?

4. SuperCoder
   Posted 5 months ago #
   

   First thing first - LCD mean local coverage determination (LCD is a set of guideline provided by Medicare/CMS) for each of the state/locality/provider type/payer type etc.
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   As i can see the LCD of Oregon (Ref - LCD ID Number L30481 & L24682) 724.5 is not a valid dx for 62311 for your state.
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   LCD Link Page -
   https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30481&ver=23&ContrId=212&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Oregon&CptHcpcsCode=62311&bc=gAAAABAAAAAA&

   ***********************

   https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=24682&ContrId=123&ver=36&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Oregon&CptHcpcsCode=62311&bc=gAAAABAAAAAA&

   *********************
   Here I would suggest you to ask doctor for another covered medical diagnosis. You can check the list of payable dx for 62311 at given link.

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   Hope this can help

5. SuperCoder
   Posted 5 months ago #
   

   Your modifier is correct however it is not necessary to attach modifier 79 in this case.

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