Posts Tagged ‘wrong surgery’

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.

Claims Appeal

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.

The Centers for Medicare & Medicaid Services (CMS) posted, Dec. 2, proposed decision memos for three national coverage determinations (NCDs) — adding to the list of “Never Events” Medicare will no longer reimburse as of March 2, 2009. Unlike Hospital Acquired Conditions (HACs), which only pertain to hospitals, these NCD-described events could also affect payment to physicians and other health care providers and suppliers involved in the following types of erroneous surgeries:

• Wrong surgery performed on a patient (CAG-00401N)
• Surgery on the wrong body part (CAG-00402N)
• Surgery on the wrong patient (CAG-00403N)

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