Medicare Denial to CPT® 64405-50 modifier

Hi I have received denial to CPT® 64405 from medicare stating as "Frequency of services exceeded".
First time i billed with units 2 to CPT® 64405. Now i have re billed with 50 modifier.

Please any one advise on this denial

re: Medicare Denial to CPT® 64405-50 modifier

Here are the steps to answering your question:

First: you have to check the Medicare Fee Schedule to see if the service is defined as unilateral or bilateral. You only apply modifier 50 to codes that are defined as unilateral. If it is already defined as bilateral, the fee is set already at 150% and includes payment for doing it on one or both sides.

There's a Codapedia article on the topic:

http://codapedia.com/article_276_How-do-I-tell-if-a-code-is-defined-as-unilateral-or-bilateral.cfm

The bilateral indicators from the fee schedule 0, 1, etc are defined.

Search the Medicare Fee Schedule here:

https://www.cms.gov/apps/physician-fee-schedule/license-agreement.aspx

After accepting the AMA agreement, search for the payment indicators. This code has a bilateral payment indicator of 1, which means it is already valued at 150%, already considered to be bilateral. You will never be paid for it twice by Medicare or any other payer that follows Fee Schedule rules.

re: Medicare Denial to CPT® 64405-50 modifier

Thanks for the detailed explanation.

I will bill 64405 with no units/modifiers

re: Medicare Denial to CPT® 64405-50 modifier

Follow-up please? So if the payment indicator status is "1" for 64405--- bilateral modifier 50 WOULD or WOULD not be correct to add (understanding that 1 unit would be billed?) The person posting the original question seems to be content in NOT using it, but I'm questioning as to why they wouldn't submit it, if chart notes warranted doing so. Guess I'm confused now. Please advise.

re: Medicare Denial to CPT® 64405-50 modifier

For code 64405, the indicator is "1" bilateral. This means the 150% payment adjustment DOES apply. 100% allowable for first side and 50% allowable for bilateral side. Add modifier -50 to code 64405 (1 unit) (Medicare)

re: Medicare Denial to CPT® 64405-50 modifier

Thank you for your time and expertise in helping to sort thru these issues. Your post has provided a great deal of relief and has settled the matter finally for me! I was beginning to second guess and that is not a good place to be --Suzanne

re: Medicare Denial to CPT® 64405-50 modifier

Glad it helped
Nancy