Modifier Mix-up Causes Claims Denials
October 5th, 2009
If your practice can’t seem to successfully bill for the professional component lately, there could be a logical explanation. It could be something as simple as an incorrect modifier.
According to First Coast Service Options Inc. (FCSO), an excessive number of claims from providers are being denied because they request payment for the professional component using the wrong modifier with the CPT® or HCPCS Level II code.
Prevent Delays and/or Denial
When billing for the professional component of a procedure, hospital outpatient departments, ambulatory surgical centers (ASCs), and other practitioners should properly identify the service by adding modifier 26 Professional component to the appropriate CPT® or HCPCS Level II code — not the new modifier effective July 1, PC Wrong surgery on patient.
Medicare automatically denies all lines related to an erroneous surgery with dates of service on or after Jan. 15, including claims for related hospitalizations.
FCSO advises providers appeal claims billed in error with modifier PC and subsequently denied for wrong surgery. Correcting and resubmitting these claims won’t work. Only an appeal will remove the edit logic that was installed for the beneficiary and date of service of the wrong surgery based on the initial claim.
Tags: CPT, FCSO, HCPCS Level II, modifier 26, PC, professional component, wrong surgery