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45385 - PT Modifier V76.51

SuperCoder Posted Thu 15th of September, 2011 14:10:44 PM

Doctor's office billed, 52 year old patient screening V76.51 that went surgerical, we used the PT modifier 76. The Doctor's office was paid at 100% leaving no deductible to the patient. How should the hospital be billing to have the patients deductible waived as well. They won't use the PCP referral V76.51 as the lead off diagnosis, they claim it went surgical they have to use the 569.3 with the 45385 leaving the patient with a deductible in the thousands. What are the guidelines for the hospital in this case?

SuperCoder Answered Fri 16th of September, 2011 08:11:56 AM

First, Most of the payer (including medicare) pays "screening colonoscopy" once a year, and in that case it will be paid 100% (without deductible).

But the above case is not the screening. It is removal of polyp (45385), so the best dx would be 211.3 not 569.3 (hemorrhage of rectum/anus).

If planned procedure is screening (45378), then V76.51 is the perfect dx, and if this converted to the surgical (45385) still we can use V76.51 along with 211.3(colonic polyp is already there), as routine screening was planned.

As per CMS/AMA, screening is payable to rule out neoplasm, hence dx V76.51 may be paid completely however if 45385 (polypectomy) is not related to the 569.3 (hemorrhage of rectum/anus), hence will not be getting 100% payment like most of the other procedure.

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