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Prokera

Jennifer Posted Tue 01st of March, 2016 15:37:22 PM

Is it acceptable to bill for Prokera the next day following superficial lamellar keratectomy with a modifier -58 if the Prokera placement is a planned procedure following SLK? More importantly, can a different provider be the one doing the second procedure? Is the issue a moot one if the SLK is done in a surgery center and the prokera placed in the clinic on the next day?
Thank you!

SuperCoder Answered Wed 02nd of March, 2016 07:16:58 AM

Reimbursement of Prokera procedure depends on certain factors. If it is a planned post-operative Prokera placement as part of a staged procedure, you may append modifier 58 on your claim. (Modifier 78 is used for unplanned procedure).
When using modifier 58, Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician."

To answer the last part of your question, CMS authorized payment for Prokera procedure irrespective of whether it is performed in the facility, and there are policies by all local Medicare carriers for coverage of this procedure. However, appending modifier 58 to ASC facility claims is considered inadvisable. Also, please check your payer policy for any specific guidelines related to this billing. Thanks.

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