Medicare Modifier

I am trying to get an old claim paid. I work for an optometrist office and I have a patient who was seen for dry eye syndrome, and his date of service fell during his cataract post op period. I submitted the 92012 with a 79 modifier and the claim was denied. I have to add that our doctors do their own coding and I just do the billing portion of it. I am really not a coder per se. I called the Medicare reopening line and I knew they couldn't give me too much information but I did find out that it has to be one of the 5* modifiers, that was all they could tell me. Am I using the wrong CPT® code? Should I be using a 99*** code? If anyone can offer some assistance, I would be very grateful. Thanks, Lori

re: Medicare Modifier

Since they told you to use a 5* mod, have you tried 58? "Staged or related procedure by same physician during global."

I'm not in the eye business anymore so I don't remember too much of the codes (plus I didn't do too much billing, more frame adjusting and such) but currently in the field I'm in we don't bill too many E&M codes (the 99*** codes) during post op. Most of our patients come back related to post op during the global so it's not usually an issue.

I hope you get your claim paid!!

re: Medicare Modifier

mod -58 will not work because that indicates it is a related dx or staged procedure, which is not the case in this scenario. As I understand it, the pt is under a global period for his cataract extraction surgery, not for the dry eye syndrome. -58 would only work if pt had another px planned and performed during the global period that was related to his cataract procedure and global service period.

re: Medicare Modifier

This is true! Thanks for the correction :) Most of my post ops are issues are related to the previous procedure so I don't encounter this much.

re: Medicare Modifier

You need to be sure you are billing with the correct dx code for dry eye syndrome. You didn't say if was bilateral, but bilateral dry eye syndrome ICD-10 code is H04123. If it isn't bilateral, you will need to look up the code. CPT® 92012 with a -79 modifier should get the claim paid, so maybe the Dr had the wrong dx code on the claim for the dry eye syndrome visit. You might need to write an appeal letter and explain that pt was seen for a dx not related to his post-op global days.
You only have I think it is 1 yr to get the claim paid after they reviewed it the first time, or maybe a year after the DOS, so time is of the essence to re-file or write an appeal. I would do BOTH and have the DR sign your appeal letter. There is no modifier starting with -5 that would help you get paid in this case, unless your DR did a exam for dry eye and the cataract surgery on the SAME DOS and then maybe a mod-59 would help, but I doubt he did that. Good luck!