Amani Posted Wed 17th of July, 2013 21:32:49 PM
The facility is billing the following procedures for one patient for the same visit:
there are CCI edit for procedure G0260 and 64493 with indicator 1. Provider need to apply the NCCI associated modifier to pass the edit. In this case, the povider append modifier 50 which is not one of the associated NCCI modifier, Is it valid to deny procedure "64493"? need please documentation to support your answer.
SuperCoder Answered Fri 19th of July, 2013 01:06:55 AM
As per the current CCI edits there is no bundling between these codes. The facility has billed it correctly.
G0260 (Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography) is a valid code, but not one that physicians should bill. You should report 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid) instead.
Heads up: Many carriers have special coverage issues or medical necessity requirements for SI injections, so check your local payer's guidelines before submitting your next claim.
As the associated NCCI modifier is concerned it is Modifier 59 not 50.
Amani Posted Fri 19th of July, 2013 19:58:27 PM
If you filter CCI edit table by Medicare, there are an edits. Filter column 1 on G0260 and in column 2, you will find procedure 64493. On the third column you will find indicator 1. Meaning an edit exist, however you can bypass the edit by adding a modifier. In this case, since the provider did not append modifier 59 to bypass the edit, can we deny procedure 64493? this is for a facility claim. thanks
SuperCoder Answered Thu 25th of July, 2013 22:47:46 PM
Very Right!! This is facility billing. You are correct in noting modifier indicator 1 which means that code 64493 is column 2 code to G0260 (col. 1 code). So a mod. 59 is required to bill 64493, if the site of injection is different (validating mod. 59 criteria).
The ASC should use the G0260 code to bill SI Joint Injections to Medicare.
The professional side (Physician claim) for SI Joint Injections should be billed to Medicare with the 27096 code.
The G0260 code is on the Medicare ASC list of covered procedures. The 27096 is NOT on the Medicare list of covered procedures.The 27096 code is for use when the ASC facility is billing SI Joint Injections to payors other than Medicare, unless they want the G-code instead. The facility would NOT bill the 27096 code to Medicare.