Medicare, why are you so fickled?!?

[bdhobbs1]

I've noticed how Medicare pays the same claim two different ways on several of our patients.  We are a billing company and we are going over all the old accounts to refile certain claims that need additional payment.

Here is what they are doing to our claims, we keep appealing and appealing until we get full payments.

Check it out, 4 examples below:

1 and 2) Medicare will pay both services on one claim and deny only the OV on another, both regardless of the modifiers used.

99205 - ov
46600 - anoscopy exam

99205 25 - ov
46600 - anoscopy exam

3 and 4) Medicare will pay both the OV and the destruction of hemorrhoids on one claim, but on another claim they will only pay the destruction, both regardless of the modifiers used.  They never pay the anoscopy exam in either situation.

99205 - ov
46600 - anoscopy exam
46934 - destruction of hemorrhoids

99205 57 - ov
46600 - anoscopy exam
46934 - destruction of hemorrhoids

[Michele]

Are you saying that Medicare will sometimes pay the ov without the modifier and sometimes with the modifier?  That makes no sense.  I can see why they wouldn't pay the ov if you didn't have the modifier but I can't see a way to explain if they sometimes pay, but sometimes don't.  I would get together a couple of examples where they paid with the modifier and without the modifier and where they denied with and without the modifier, then call Medicare and ask them to explain the difference.

Michele

[bdhobbs1]

Are you saying that Medicare will sometimes pay the ov without the modifier and sometimes with the modifier?  That makes no sense.  I can see why they wouldn't pay the ov if you didn't have the modifier but I can't see a way to explain if they sometimes pay, but sometimes don't.  I would get together a couple of examples where they paid with the modifier and without the modifier and where they denied with and without the modifier, then call Medicare and ask them to explain the difference.

Michele

yes, they sometimes pay and sometimes deny the OV with or without the modifier.

[Michele]

That is strange, I would definitely call and ask for an explanation.

Michele

[marypete]

When you bill the office visit (99205 25) are you submitting a different diagnosis as the reason for the office visit?  If the patient is being seen just for the anoscopy with a related diagnosis then Medica is not going to pay it separately.  You have to have a diagnosis not related to the reason for the anoscopy.

Medicare is not going to pay for an anoscopy if it was done iin order to remove the hemmoroids.  It is considered part of that procedure.  You would have to show that it was done for a different reason in order to get paid for it.