Author Topic: billing 43580 and 43235  (Read 472 times)

sls

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billing 43580 and 43235
« on: December 19, 2016, 02:50:36 PM »
i billed these two procedures was denied for 43235 as non covered benefit. what modifier do I need I was thinking 51 but not sure.

kristin

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Re: billing 43580 and 43235
« Reply #1 on: December 19, 2016, 07:36:43 PM »
So the patient had a colonoscopy and an endoscopy done in the same session? You say the endoscopy was denied as a non-covered benefit. That indicates to me that there is something wrong with the diagnosis code used, and the patient's insurance does not pay for the procedure when done for what was diagnosed.

You would not use a 51 modifier, those are assigned on the payer's end, to reduce payment on multiple surgical procedures done at the same time/session. You could use a 59/X_ modifier, if CCI edits allow it to be used on the 43235 when done with a 43580, but you would have to check the edit on that.

Still, it sounds like the problem based on the denial reason you gave has nothing to do with modifiers, but rather diagnoses. Another thought is maybe the insurance will not pay for both procedures to be done on the same day.