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Special Payment Rule for Multiple Endoscopies

Apurva Posted Thu 16th of May, 2019 06:10:12 AM
For NHP Medicaid plans (integrity and exchange) can we bill 45385 , 45380-51-59 when both Colonoscopy with snare technique is performed. We have been receiving denials stating "needs an additional modifier for multi-procedure" if we are billing with either one of the Modifiers (51/59 ) along with CPT 45380.
SuperCoder Answered Fri 17th of May, 2019 04:31:11 AM

Hi Apurva,


Thanks for your question.


Please note that there is CCI edit between codes 45385 and 45380. So you cannot report both the codes together when performed during the same session. Code 45385 should only be reported being column 1 code. But in case both the codes are necessary and have been performed on the same DOS but on different sessions, then you may bill both codes together since the modifier is allowed. Append modifier 59 with code 45380 being column 2 code.


Now the important thing to note is that you need to append modifier 59 first to unbundle the codes and then 51.


If you face any problem, please feel free to write to us.



Apurva Posted Fri 17th of May, 2019 05:21:03 AM
Per Multiple reduction procedure policy MODIFIER 51 needs to be appended first followed by 59 ?
SuperCoder Answered Mon 20th of May, 2019 09:04:44 AM

Medicare doesn’t recommend reporting Modifier 51 on the claims. Some private payers also do not allow modifier 51. Moreover, please let us know which place of service (POS) you are billing for?



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