Medical Billing Forum
Coding => Coding => : shelbylmk June 27, 2019, 06:15:10 PM
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I work for a DME provider. I have a claim that is denying out stating that it is part of a global procedure and they are refusing to pay for this back brace. The patient in question had a spinal fusion done on 12-7-2018 and on 12-10-2018 she got a back brace from one of our storefronts. So I went to my supervisor who advised me to use the modifier 59 and submit a corrected claim, which I did do. Now, it is denying out for the modifier being incorrect. Could I use the modifier 25 on the claim? Its been a while since I have used modifiers. Thanks for any help.
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It is the back brace that is denying? The 59 modifier would not be appropriate for a DME product. Neither would the 25 modifier. I'm confused, a back brace should not be denying out as part of a global procedure. I would call to see what there explanation is for the original denial. A piece of equipment cannot be considered as part of another procedure. It may not be covered by the plan, or they may not allow it following surgery if they feel the surgery corrected the problem, but it shouldn't be denying as part of the surgery.
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Yes the back brace is denying out. My manager and I both called the insurance co who told us both the same thing regarding the denial that a modifier needs to be used. I think that I need to call the insurance back again to see if I could get more info out of them because I feel like that I wouldn't need a modifier. Especially, since the surgical date is different then the day that the patient received the back brace. Thank you for your help.
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What insurance is it?
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Especially, since the surgical date is different then the day that the patient received the back brace. Thank you for your help.
This is just a guess..but could the brace be considered part of the global surgical package? I know some surgeries that require braces for back surgery are usually included. What line items are you bililng the brace with?