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Medicare, Medicaid, Life and Health Insurance/Pre-op x-ray coding for Medicare submittal

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QUESTION: For Pre-op X-rays; What Modifier Needs To Be Suffixed To Code 71020 When Patient Is A Smoker, AND Has Atrial Fibrillation?

Medicare has denied my wife's claim that was coded with the basic 71020, and I have been told that if the correct 'justifying' modifier / suffix is used, Medicare will approve.

(FWIW, Surgery was for cataract removal.)

ANSWER: Hi Frank

I can't say for sure which modifier is needed because different situations may require one of four different modifiers: Modifier 59, 76, TC, 26.  The facility that the x-rays were performed should be able append the appropriate modifier and rebill the claim.

Just an FYI - Modifier 26 is used for services performed by the physician, and TC is for the use of the x-ray equipment.  

I do not have all the details about your wife's claim so I can't tell you for sure which one needs to be on the claim but you can start by calling the facility that the bill is for.  There are different billing methods depending on where the x-rays were taken and who performed them.

Thanks for the question.

---------- FOLLOW-UP ----------

QUESTION: Thanks Joy; I'll use your response to talk to the diag lab, who performed the x-ray service. (The reason I'm here, asking my question at AllExperts, is that the lab seems lost as to how to answer the question. Hence, discussing with them cannot be productive.)

I'm thinking, from your answer, and what I've read on line, is that we're talking about modifier -76. (From what I've read, -59 is a widely MISused modifier??? It gets used too often as a "catch-all / miscellaneous" category???)

Can you confirm for me, now with the knowledge that the service was performed at a lab, external to the doctor's office, that -76 IS the most likely accurate mod to use? THANKS!

Answer
I can't confirm the 76 modifier.  There is still some information missing.  Modifier use is supposed to be used with very specific variables.  The lab is the only one who can accurately determine which modifier to use.  There are too many "if this, then use" scenarios that are needed to accurately code modifiers.  My suggestion to you - instead of trying to tell them which modifier to use, I would try to get a Medicare representative and the billing department on a three way call to see if they work together to resolve this bill for you.

Good Luck!

Medicare, Medicaid, Life and Health Insurance

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Joy B. Hicks, MBA, CPM

Expertise

As a Medical Office Expert, I can answer any question related to the medical office from the prospective of hospital and physician office staff and patients.

Experience

I have been in the medical office field for 12 years and also have a blog that provides advice, information, and tips about the medical office.

Publications
medicaloffice.about.com
askamedicalbiller.com
allthingsmedicaloffice.blogspot.com

Education/Credentials
Certified Practice Manager
AAS Business Administration
BA Health Care Administration
MBA w/ healthcare specialization

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