Forum - Questions & Answers

Aug 26th, 2015 - NEOSM

Shoulder Surgical Coding

Hello Everyone~

I have a patient we billed the following:

23430 lt
29819 lt
29820 59lt
29822 59lt

I received a denial from NYS WC carrier stating that 29820 was denied as it was performed in the same location as 29822. I reviewed this with the provider and they claim this should be paid because it is a separate and distinct procedural service.

I reviewed AAOS codex and 29820 is considered global but also allows for the "59" modifier per NCCI edits.

Has anyone else had this type of denial? Any help is greatly appreciated!


Aug 26th, 2015 - petunia 195 

re: Shoulder Surgical Coding

Is there justification for the for both procedures to be billed together. If both were done on the left shoulder and there was not a seperate site or incision or something else that would make it justifialbe to bill both I would not bill both of those together.

Distinct Procedural Service:
Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in
extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is
appropriate, it should be used rather than modifier 59.

Aug 26th, 2015 -

re: Shoulder Surgical Coding

Thank you for the prompt response, but I believe it was for visualization and would be global.

Thanks for your help!!!!!

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