Mabel Posted Thu 06th of October, 2011 15:58:32 PM
We are getting denials recently for claims using code '64612' with modifier '50' as not being an appropriate modifier for the CPT code. I can't find any documentation that verifies this. On the contrary, I believe the documentation supports our use of the modifier with the CPT code. Is there something I'm missing? Please help.
SuperCoder Answered Thu 06th of October, 2011 21:55:07 PM
For CPT 64612, if you will check CMS site or SuperCoder site, you will find the info, the modifier indicator is 1.
Modifier Indicator 1 implies 150% bilateral payment adjustment applies. Payment for bilateral procedure (e.g., 50, RT/LT, 2 units) is lower of (a) actual charge for both sides or (b) 150% of fee schedule amount for single code. Apply bilateral adjustment before multiple procedure rules.
Please contact the Insurance rep regarding this, and ask for the correct reason of denial citing the above info.
Mabel Posted Mon 10th of October, 2011 15:56:32 PM
Thank you for your response, but you don't seem to quite understand the question. I am dealing directly with the insurances and still having problems. Is this the "expert" response? I don't see what your credentials are.
SuperCoder Answered Mon 10th of October, 2011 19:57:28 PM
I think Sanjit has cited the guidelines. The denial with 64612-50 is of higher frequency irrespective of the correctness of coding many times because the issues involved can be varied and mostly payor preference dominates. So, the last line is enough. Coders in different forums use to have varied response in this regard because of the uncertainty of its reimbursement.
He has been great for me many times.