We recently provided a consultation service for a patient who has BC/BS primary and Medicare secondary. Medicare picked up the co-insurance for other services rendered that day, but denied the consultation service. Do I bill the patient for the balance or must I write it off?
CMS directs providers to use the new or established visit codes instead of the consultation codes, so it would be against the rules to bill the patient for what is left of a consultation charge. In billing the new or established patient codes you lose a little overall, but will get paid for the new or established E/M if all requirements are met. (For more on this, see the April 2010 column available online at PracticalDermatology.com) Also, do not bill a consultation to the primary and then change it to a new or established patient code to bill Medicare.
I heard that when it is necessary to use the same code more than once on the same day for the same patient, such as two Mohs sites on the face, the second one should be modified with 59, and that 76 should never be used in dermatology. However, when I billed Medicare with modifier 59 for two Mohs cases on the same day, the second Mohs case was denied. I rebilled it with modifier 76 and it was paid. What gives?
The following language is included in the definition of modifier 59: “...However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.” Because modifier 59 was created to be used with Medicare's Correct Coding Initiative (CCI), some Medicare payers require their providers to use 59 only in conjunction with the Correct Coding Initiative, and will deny claims not related to the CCI.
Modifier 51 would not address the issue, as its purpose is simply to indicate that multiple procedures were performed on the same day (used for multiple surgery reduction). That leaves modifier 76 as the only viable option. It may be necessary to find out from each payer which modifier to use under these circumstances.
After practicing for three years I just discovered that 17003 and 11101 are billed for each additional lesion, not just once for all additional lesions. So I have two questions: 1. How should I have known that? 2. Is there any way I can get paid now?
The way to tell whether a code is to be billed at more than one unit is that in its CPT description there will be wording such as, in the case of 17003, “second through fourteen lesions, each (List separately in addition to code for first lesion.)” For additional biopsies, 11101, the language is: “each separate additional lesion, (List separately in addition to code for primary procedure.)”
As to whether you can get paid, you can try for all of those claims for which the filing deadline has not been exceeded. You should be able to identify the patients by running a report of all patients for whom the primary codes were billed, then access the records to see how many lesions were treated. Whether you bill the entire visit, including codes that have already been paid, or just the previously unbilled codes will depend on the payer. It is best to contact the payer before sending the claims.