Hattiesburg Posted Tue 15th of May, 2018 15:14:05 PM
We performed a CT of the neck, with contrast, a CT of the chest, with contrast, and a oncological whole body PET scan on the same DOS (all services were ordered due to oncological diagnosis). We had to split bill the CT studies due to different reading/supervising radiologist. We billed the appropriate 26/TC modifier with the CT studies and received a denial from Humana Advantage for "frequency/number of services not supported". An XU modifier was added to the 26/TC studies and they are still denying the claim, stating the modifier is incorrect. I read in one of the SuperCoder publications that modifier 51 should not be used with Medicare. How do we bill these studies?
SuperCoder Answered Wed 16th of May, 2018 02:42:32 AM
CT of neck and chest have both a technical and professional component. To report only the professional component, append modifier 26. To report only the technical component, append modifier TC. To report the complete procedure (i.e., both the professional and technical components), submit without a modifier.
Hattiesburg Posted Mon 21st of May, 2018 12:18:25 PM
I think you misunderstood my question, or maybe I wasn't very clear - we understand how to split bill the services. These are the CPT codes we billed for this date - 71260, 70491, 78816, A9552 and Q9967. They are denying CPT 71260,26,XU; 71260 TC,XU; 70491 TC,XU , as "Frequency/number of services not supported". They denied 70491 26,XU for procedure inconsistent with modifier or modifier is missing. They paid the A9552, 78816 and Q9967. We don't understand why they denied the CT services and are trying to determine if it is because they were performed/billed on the same DOS as the PET scan (78816). The CT services were only split billed because there was different performing and interpreting providers for the CT services.
SuperCoder Answered Tue 22nd of May, 2018 08:47:47 AM
The team is working on query.
SuperCoder Answered Wed 23rd of May, 2018 07:16:47 AM
According to the general coding guidelines, all the codes can be billed together.
According to the CMS, for CPT 71260, some state specific guidelines says, “reasonable and necessary imaging which is felt to be required more frequently than six times a calendar year must have substantial documentation to describe medical necessity”. Hence check your billing counts for the patient for the calendar year.
Also, for CPT 70491, it is suggested that “each supervising physician must be limited to providing general supervision to no more than three Independent Diagnostic Testing Facility (IDTF) sites.
This might be the reason of denial for both the CPT codes.
Check your payer policies and re-submit the claim accordingly.